Resumo em Português:

OBJETIVO: Avaliar o significado prognóstico da espessura tumoral no carcinoma epidermóide de boca e orofaringe. MÉTODO: Foram avaliados retrospectivamente 112 pacientes atendidos entre janeiro de 1990 e dezembro de 1994, dos quais foram selecionados 84 casos com amostras teciduais disponíveis. A medida da espessura foi realizada à microscopia óptica com ocular milimetrada, considerando a maior medida perpendicular à superfície. RESULTADOS: A incidência de metástases ocultas foi de 7% nos tumores menos espessos do que 3mm e 50% naqueles com espessura igual ou superior a 5mm. As margens cirúrgicas estiveram comprometidas com maior freqüência nos pacientes com espessura tumoral maior ou igual a 5mm, mas a espessura não identificou os pacientes com maior risco de recidiva local. CONCLUSÃO: A espessura tumoral auxilia a identificar os pacientes com carcinoma epidermóide de boca e orofaringe com maior risco de metastatização oculta.

Resumo em Inglês:

BACKGROUND: To evaluate the prognostic meaning of tumor thickness in squamous cell carcinoma of the mouth and oropharynx. METHOD: A retrospective study of 112 patients treated between January 1990 and December 1994 was undertaken and 84 cases with tecidual samples were selected. Tumor thickness was measured by optical microscopy, considering the largest perpendicular measure. RESULTS: The incidence of occult metastases was 7% in tumors less than 3 mm and 50% in those 5 mm or more in thickness. Surgical margins were compromissed more frequently in patients with tumor thickness of 5 mm or more, but mesure of tumor thickness was not prone to identify patients with larger risk of local recurrence. CONCLUSION: Tumor thickness aids to identify patients with squamous cell carcinoma of the mouth and oropharynx with higher metastatic risk.

Resumo em Português:

OBJETIVOS: Identificar por imunoistoquímica eventuais micrometástases nos linfonodos regionais previamente considerados livres pelo exame histopatológico convencional e avaliar a influência do comprometimento destes linfonodos na sobrevivência dos doentes com carcinoma colorretal extirpado com intenção curativa. MÉTODO: Foram estudados 51 doentes portadores de carcinoma colorretal nos estádios A (13 casos) e B (38 casos), segundo a classificação de Dukes. Um total de 501 linfonodos previamente considerados livres pelo exame histopatológico convencional foi investigado por meio de técnica imunoistoquímica com anticorpos monoclonais anticitoqueratina AE1/AE3 para identificar células epiteliais. Cada bloco previamente fixado em formalina e embebido em parafina foi seccionado em três partes, obtendo-se de cada uma delas três cortes com espessura de 4 milimícron cada. RESULTADOS: Em seis doentes (11,7%) no estádio B de Dukes, células neoplásicas foram identificadas em sete linfonodos do mesocolo (1,4%) previamente considerados livres de neoplasia pelo exame histopatológico convencional. Em um enfermo, a micrometástase era representada por aglomerado celular, enquanto que nos outros cinco doentes as micrometástases eram constituídas por células isoladas. A sobrevivência dos enfermos com micrometástases linfonodais foi menor do que a dos doentes com linfonodos não comprometidos, porém sem atingir diferença significativa. CONCLUSÕES: O método imunoistoquímico pode ser empregado com sucesso na detecção de células neoplásicas em linfonodos previamente considerados livres pelo exame histopatológico convencional. O acometimento dos linfonodos regionais por micrometástases não influenciou a sobrevivência dos doentes com carcinoma colorretal extirpado.

Resumo em Inglês:

BACKGROUND: To identify possible micrometastases by immunohistochemistry, to verify their morphological characteristics in regional lymph nodes and to evaluate their influence on the survival of patients with colorectal carcinoma that had been extirpated in a curative intent. METHOD: A study was made of 51 patients with colorectal carcinoma in stages A (13 patients) and B (38 patients), according to Dukes classification. A total of 501 lymph nodes previously considered free by conventional histopathological examination were submitted to immunohistochemical study using the technique of AE1/AE3 anticytokeratin monoclonal antibodies for the detection of neoplastic epithelial cells in their interior. Three serial sections, with three slices per section, with 4 millimicron were prepared from each slice. RESULTS: Neoplastic cells were identified in six patients (11.7%) at stage B in the Dukes classification, in seven lymph nodes of the mesocolon (1.4%) previously considered free of neoplasia by conventional histopathological examination. In one case, micrometastasis was represented by a cell agglomeration, while in the other five cases, it was made up of isolated cells. Survival of patients with extirpated colorectal cancer with lymph node metastases was less than for the group of patients with involved lymph nodes, although without presenting a significant difference. CONCLUSIONS: The immunohistochemical method may be employed for the detection of neoplastic cells in lymph nodes previously considered free by conventional histopathological examination. The presence of a micrometastasis in regional lymph nodes did not significantly influenced survival of patients who had colorectal carcinoma extirpated with curative intent.

Resumo em Português:

OBJETIVO: Demonstrar nossa experiência com a gastroplastia em Y de Roux por videolaparoscopia (GYRL), usando pequena bolsa gástrica e anastomose jejunal com grampeador circular. A gastroplastia com desvio em Y de Roux é uma das operações mais comuns para o tratamento da obesidade mórbida. Técnicas por laparoscopia têm sido relatadas, mas descrevem maior tempo operatório e maiores complicações quando comparadas com a cirurgia aberta. A abordagem por videocirurgia continua a ser um desafio mesmo para os cirurgiões mais experientes. MÉTODO: De setembro de 1999 a maio de 2001, 102 pacientes foram submetidos à gastroplastia em Y de Roux. A anastomose jejuno-jejunal foi feita a uma distância de 100cm a 150cm de acordo com o índice de massa corporal (IMC). Uma análise prospectiva identificou o índice de fístula e de estenose pós-operatória e a conduta em uma série consecutiva de pacientes, submetidos a GYRL com anastomose gastrojejunal realizada com grampeador circular 25mm ou 28mm. Nos últimos dez casos esta anastomose foi executada com sutura manual. RESULTADOS:. A média etária foi de 37,5 anos (17-62) e a média de IMC foi de 50,3kg/m² (35-78). O tempo operatório variou de 55min a 210min com média de 119min. O tempo médio de internação foi 4,3 dias (2-10). Dois pacientes superobesos tiveram a cirurgia convertida para o procedimento aberto por dificuldades técnicas. Houve dois óbitos (1,9%), ambos por embolia pulmonar. Houve uma fístula (0,9%) da anastomose gastrojejunal tratada conservadoramente. Quinze pacientes (14,7%), desenvolveram estenose na anastomose e necessitaram de dilatação endoscópica. Nove pacientes sofreram uma única dilatação e seis receberam duas a quatro dilatações e permaneceram sem disfagia. Vinte pacientes foram avaliados após um ano e mostraram uma média de IMC 33,4kg/m² (24-44). CONCLUSÃO: A GYRL com anastomose gastrojejunal com grampeador é segura e efetiva. Ocorreram estenoses que foram tratadas com dilatação endoscópica, mas, com o uso do grampeador circular de 28mm ou sutura manual, não mais aconteceram. Os dois óbitos ocorreram em superobesos, em que a intervenção foi convertida para procedimento aberto e evoluíram com embolia pulmonar irreversível.

Resumo em Inglês:

BACKGROUND: Roux-en-Y gastric bypass is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but refer longer operative time and seemingly higher initial complication rates as compared to the open procedure. The minimally invasive aproach continues to be a challenge even to the most experienced laparoscopic surgeons. The purpose of this paper is to describe our experience with the laparoscopic Roux-en-Y gastric bypass (LRYG), using a gastric pouch to jejunal anastomosis with a EEA stapler. METHOD: From September 1999 to May 2001, 102 patients were submitted to LRYG, using a gastric pouch jejuno anastomosis with a EEA stapler. Jejuno-jejunal anastomosis was carryed on at a distance of 100cm to 150cm according to the body mass index (BMI). A prospective analysis was undertaken to identify technical success, leak rate and postoperative incidence of anastomotic stenosis and its management, in a consecutive series of patients undergoing LRYG, with gastrojejunal anastomosis performed with a 25mm or 28mm stapler. In the last 10 cases this anastomosis was carryed on by hand suture. RESULTS: Mean age was 37,5 years (range 17-62) and mean BMI was 50,3kg/m² (range 35-78). The mean operative time was 119min. (55-210). The mean postoperative hospital stay was 4,3 days (2-10). Two super obese patients were converted to an open precedure for technical difficulties. Two patients died (1,9%) both from pulmonary embolism. There was 1 leak (0,9%) from the gastrojejunal anastomosis managed without operation. Fifteen patients (14,7%) developed anastomotic stenosis, that required endoscopic baloon dilatation. Nine of them required only a single dilatation and had no recurrence of dysphagia. Six needed 2 to 4 dilatations and all of them are swallowing normaly. In twenty patients, after 12 months of follow-up, the mean decrease in BMI was 21,1kg/m². CONCLUSIONS: LRYG with the stapled EEA gastrojejunal anastomosis is safe and effective. Stenosis ocurred and were managed by endoscopic dilatation, but with the use of EEA 28 or hand suture, they did not happen anymore. There were two deaths in super obeses patients whose operations were converted to open procedure and developed pulmonary embolism.

Resumo em Português:

OBJETIVO: Estudar os efeitos da isquemia e reperfusão hepática total sobre acúmulo de neutrófilos no íleo terminal e cólon sigmóide de ratos, em condições de normalidade e submetidos ao estado de choque hemorrágico controlado. MÉTODO: 32 ratos Wistar, machos, foram divididos em quatro grupos de oito animais cada: grupo Sham, submetido aos procedimentos padrões com um período de 60 minutos de observação; grupo Choque, submetido a choque hemorrágico controlado (PAM = 40mmHg, 20min) seguido de reposição volêmica (Ringer lactato + sangue, 3:1) e reperfusão (60min); grupo Pringle, submetido à isquemia hepática total (15min.) e reperfusão (60min); grupo Total submetido a choque hemorrágico controlado (20min) seguido de reposição volêmica (Ringer lactato + sangue, 3:1), isquemia hepática (15min) e reperfusão (60min). Após o sacrifício dos animais, procedeu-se à contagem de neutrófilos nos segmentos intestinais. RESULTADOS: Na contagem de neutrófilos no íleo terminal, apenas o grupo Choque diferiu dos demais (p<0.001) os quais não diferiram entre si (Sham 1.33 ± 0.55, Choque 5.48 ± 2.65, Pringle 2.47 ± 1.38, Total 2.44 ± 0.56) e, no cólon sigmóide, o grupo Choque diferiu apenas do grupo Sham (p = 0.021), sem diferença entre os demais (Sham 0.66 ± 0.44, Choque 2.08 ± 1.11, Pringle 1.04 ± 0.71, Total 1.21 ± 1.03). CONCLUSÃO: Diferentemente do estado de choque hemorrágico controlado, a isquemia hepática de 15 minutos, seguida de 60 minutos de reperfusão, não causou acúmulo significativo de neutrófilos no íleo terminal e cólon sigmóide.

Resumo em Inglês:

BACKGROUND: The purpose of this experimental work was to study the effects of total hepatic ischemia and reperfusion on the accumulation of neutrophils in the terminal ileum and sigmoid colon of rats, under normal conditions and under controlled hemorrhagic shock. METHOD: Thirty two adult male Wistar rats, were divided into four groups: Sham group, was submitted to standard procedures for a period of 60 min. of observation; Shock group, was submitted to controlled hemorrhagic shock (mean arterial blood pressure = 40mmHg, 20 min.) followed by fluid resuscitation (lactated Ringer's solution + blood, 3:1) and reperfusion for 60 min.; Pringle group, was submitted to total hepatic ischemia for 15 min. and reperfusion for 60 min.; Total group, was submitted to controlled hemorrhagic shock for 15 min. followed by volemic resuscitation (lactated Ringer's solution + blood, 3:1) and reperfusion for 60 min. Neutrophils counting on intestinal tissues was performed after euthanasia. RESULTS: Values for neutrophils counting on the distal ileum indicate that, only animals from Shock group differed from other groups (p<0.001) (Sham 1.33±0.55, Shock 5.48±2.65, Pringle 2.47±1.38, Total 2.44±0.56). On sigmoid colon, Shock group differed only from Sham group (p=0.021) and did not differ from other groups (Sham 0.66±0.44, Shock 2.08±1.11, Pringle 1.04±0.71, Total 1.21±1.03). CONCLUSIONS: Differently from hemorrhagic shock, total hepatic ischemia for 15 minutes, followed by 60 minutes of reperfusion, did not present significant neutrophils accumulation on distal ileum and sigmoid colon tissues.

Resumo em Português:

OBJETIVO: Analisar as lesões abdominais e seu impacto no prognóstico dos traumatizados com fraturas de bacia MÉTODO: Avaliamos retrospectivamente todos os prontuários das vítimas de trauma fechado com fraturas de bacia admitidos de 1996 a 2000. Nossa amostra incluiu 224 doentes, com média etária de 34 + 16 anos, sendo 137 (61,1%) do sexo masculino. Dados demográficos, índices de trauma, órgãos lesados, tratamento e evolução foram estudados. As lesões abdominais foram estratificadas pela Organ Injury Scale (OIS), Abbreviated Injury Scale (AIS) e Abdominal Trauma Index (ATI). Empregamos os testes Qui quadrado e t de Student, considerando p<0,05 como significativo. RESULTADOS: O mecanismo de trauma mais comum foi o atropelamento, em 119 casos (53%). As médias dos Revised Trauma Score (RTS) e Injury Severity Score (ISS) foram 7,0341+1,864 e 20,2 + 12,8. As lesões abdominais ocorreram em 95 (42,4%) doentes, sendo a bexiga o órgão mais freqüentemente lesado (11%). Sessenta e três (28,1%) traumatizados tiveram AIS> 3 e 54 (24,1%) OIS > 3 em órgãos abdominais. A média dos ATI foi 9 + 8 nos com lesões abdominais diagnosticadas. Foram realizadas 55 laparotomias (nove não terapêuticas). Cinqüenta e um (22%) doentes morreram, principalmente devido ao choque hemorrágico (25 casos). A presença de lesões abdominais esteve relacionada significativamente com choque à admissão, fraturas complexas de bacia, fixação externa ou interna da fratura de bacia, maior morbidade e letalidade. CONCLUSÃO: As lesões abdominais são freqüentemente associadas às fraturas de bacia, e, quando presentes, relacionam-se a um pior prognóstico.

Resumo em Inglês:

BACKGROUND: To analyze possible abdominal injuries and their impact on the prognosis of patients sustaining pelvic fractures. METHOD: Retrospective chart review including all victims of pelvic fractures due to blunt trauma from 1996 until 2000. Sample was constituted of 224 patients, mean age 34 + 16 years, 137 (61,1%) male. Demographic data, trauma indices, organs injured, treatment and evolution were assessed. Abdominal injuries were graded using Organ Injury Scale (OIS), Abbreviated Injury Scale (AIS) and Abdominal Trauma Index (ATI). Statistical analysis was carried out with student's t and chi square tests. RESULTS: Pedestrian struck was the most common mechanism of injury (53%). Mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.0341 ± 1.864 and 20.2 ± 12.8 respectively. Injuries in abdominal organs were found in 95 patients (42,4%), being the bladder the most frequently injured (11%). Sixty three (28,1%) patients had their abdominal injuries graded as AIS > 3, and 54 (24,1%), as OIS > 3. Mean ATI for those sustaining abdominal lesions was 9 ± 8. Fifty five laparotomies were performed, nine of them being non therapeutic. Fifty one patients died (22%), mainly due to hemorrhagic shock. The presence of injuries to abdominal organs were significantly associated with shock upon admission, complex pelvic fractures, external fixation of the pelvic fracture, increased number of complications and higher mortality (p<0.05). CONCLUSION: Abdominal organs are frequently injured in patients sustaining pelvic fractures and, when present, determine worse prognosis.

Resumo em Português:

OBJETIVO: Analisar os principais aspectos técnicos e clínicos referentes às ressecções hepáticas realizadas em um período de cinco anos (1994 a 1998). MÉTODO: Estudo retrospectivo de 21 ressecções hepáticas, com ênfase no tipo de ressecção utilizado, o preparo pré-operatório e as complicações do período pós-operatório. Ademais, estabelecer correlações com os dados clínicos e epidemiológicos, bem como os exames complementares mais solicitados, em especial, o exame histopatológico. RESULTADOS: Foram realizadas oito ressecções locais atípicas, quatro segmentectomias, quatro hepatectomias esquerdas, duas hepatectomias direitas, uma lobectomia esquerda, uma trissegmentectomia esquerda e uma trissegmentectomia direita. As ressecções foram indicadas para tratamento de tumores malignos primários do fígado em nove pacientes; tumores benignos em seis pacientes; miscelânea em três pacientes; metástases hepáticas em dois e tumor de via biliar em um paciente. As complicações pós-operatórias ocorreram em sete pacientes (33%), sendo as mais freqüentes o abscesso subfrênico e peritonite e a mortalidade operatória foi de 9,5%. CONCLUSÕES: A cirurgia hepática tem se tornado cada vez mais factível e as complicações pós-operatórias, sob maior controle clínico, têm diminuído bastante a mortalidade.

Resumo em Inglês:

BACKGROUND: To analyse the main clinical and technical aspects related to hepatic resections in a 5-year period (1994 to 1998). METHOD: This is a retrospective study of twenty one hepatic resections and enphasizes resection type used, pre-operative preparation and post-operative complications. It also stablishes corelations between hepatic resections and clinical and epidemiological data and between hepatic resections and complementary tests more frequently required, specially histopathological test. RESULTS: There were eight atipical local resections, four segmentectomies, four left hepatectomies, two right hepatectomies, one left lobectomy, one left trisegmentectomy and one rigth trisegmentectomy. Resections were indicated for the treatment of primary malignant liver tumors in nine patients; for benign tumors in six patients; for miscellany in three patients; for hepatic metastasis in two and for billiary ducts tumor in one patient. Post-operative complications occurred in seven patients(33%). The main complications were the subfrenic abscess and peritonitis and the operative mortality was of 9,5%. CONCLUSIONS: Hepatic surgery has become increasingly performed and post-operative complications have undergone a stronger clinical control, reducing significantly mortality.

Resumo em Inglês:

Hyperparathyroidism is a desease caused by increase of parathormone secretion, leading to a misfunction of calcium metabolism. Although not very common among population in general, it is frequently observed in patients with cronic renal disease. It can involve a slight syntomatic form, but as a whole, its main repercurssions occur in skeletic muscles, urinary and intestinal systems. The authors conduct a broad revision of the literature, focusing on the methods of diagnosis and spot checking before and during the operations of parathyroid glands. Surgical recommendations, tatic aspects and types of surgery to be implemented are discussed. A systematization for adequate surgical technics performed at the General Surgery Service of Clementino Fraga Filho Hospital of Federal University of Rio de Janeiro is fully discribed and recommended.

Resumo em Inglês:

Mesenteric cyst is a rare abdominal disease, with a higher incidence among women and 1: 250.000 incidence among hospitalized adults and 1: 200.000 among hospitalized children. Thereby, we report a case of a 10 years old child, male, presenting a large mesenteric cyst, which occupied almost all the abdominal and pelvic cavities and treated by resection during laparotomy.

Resumo em Inglês:

Bezoar is a foreign body in the digestive tract originated from ingestion of varied substances, mainly vegetal hair or coats, staple fibers among others. We present a case of a 16-year-old female with trichotillomania history of approximately 5 months, diagnosed through clinical evidence of traumatic alopecia made by her dermatologist. Though asymptomatic the presence of tricobezoar was suspected and confirmed through digestive seriography and high digestive endoscopy. The patient was operated on for gastrotomy and removal of bezoar, with good postoperative follow-up, except for surgical wound infection.

Resumo em Inglês:

Primary adenocarcinoma of the duodenum is an extremely rare disease, and represents only 0.35% of all gastrointestinal malignancies. Early detection of the disease may be difficult because of the absence of pathognomonic symptoms. The authors relate one case of a adenocarcinoma of the duodenum in a 61-year-old white man with a history of abdominal pain for a six-month period, associated with postprandial fullness, vomiting and weight loss. Contrasted x-ray and computerized tomography showed a tumor in the fourth segment of the duodenum, with partial obstruction of the lumen. Histological study revealed a moderate differentiated adenocarcinoma. Treatment consisted of resection of the fourth portion of duodenum. The authors comment on the most important aspects of this pathology.

Resumo em Inglês:

Two types primary epithelial tumours of the kidney have been distinguished, such as renal cell carcinoma (hypernephroma or Grawitz) deriving from proximal tubules and carcinoma arising in the urothelium of the kidney's collecting system. Mancilla-Jimenez e cols were the first to describe in 1976 an atypical papillary carcinoma of the kidney deriving from collecting duct system-Bellini duct carcinoma (BDC). In the World Healthy Organization classification it is listed as a rare carcinoma ( 1 % of the renal malignancies) originating in the renal medulla. Histologic examination shows both tubular and papillary architeture, which can lead to misinterpretation as renal cell or transitional cell carcinoma. Renal cell carcinoma originates from the metanephrogenic blastema and collecting duct carcinoma derived embryologicaly from the mesonephron Wolff duct. Renal cell carcinoma has been shown to express both cytokeratins and vimetin, whereas the distal convoluted tubule expresses only cytokeratins. BDC can be considered as a renal malignancy with a very bad prognosis compared to the other renal cell carcinoma. The best treatment is radical nephrectomy. A case of BDC is reported in a young black man, 27 year old with only history of light left back pain. Ultrasound and other image examinations showed a tumour about 6 cm in the middle and low left kidney. Patient was submitted to extraperitoneal radical nephectomy. Microscopic evaluation revealed kidney's collecting duct carcinoma with metastasis on two retroperitoneal lymphy nodes.

Resumo em Inglês:

The authors report a case of acute gastric volvulus in a 20-year-old male, complicated by perforation near the gastroesophageal junction and generalized peritonitis. This is an uncommon and potentially lethal conditon although our patient has been handled successfully with a partial gastrectomy.