Resumo em Português:

O nosso objetivo é determinar prospectivamente o número, tamanho e tipo de cálculos da vesícula biliar de trezentos pacientes consecutivos submetidos à colecistectomia. O tipo de cálculo foi correlacionado com o sexo e idade dos pacientes, o tamanho e o número de cálculos e a presença de colecistite aguda e de displasia da vesícula biliar. Cálculo de colesterol foi encontrado em 262 pacientes (87,3%), pigmentar negro em 33 (11 %) e pigmentar marrom em cinco (1,7%). Todos os tipos de cálculos foram mais comuns no sexo feminino e aumentaram com a idade. O cálculo de colesterol foi mais comum em todas as faixas etárias. O número de cálculos variou de um a 465, sendo que a metade dos pacientes apresentou menos do que cinco cálculos. Cálculo único foi encontrado em 65 dos 262 pacientes (24,8%) com cálculo de colesterol, em um dos cinco pacientes (20%) com cálculo pigmentar marrom e em nenhum paciente com cálculo pigmentar negro. A incidência de colecistite aguda foi similar para os três tipos de cálculos. Não houve diferença na incidência de displasia da vesícula biliar em relação ao número, tipo e tamanho de cálculo. Conclui-se deste estudo que os cálculos de colesterol são os mais comuns da vesícula biliar, independente da idade e do sexo dos pacientes. Apesar do número de cálculos ser extremamente variável, metade dos pacientes submetidos à colecistectomia por litíase apresenta menos do que cinco cálculos. Pacientes com cálculo pigmentar preto não apresentam cálculo único.

Resumo em Inglês:

Our objective is to prospectively determine the number; size, and type of gallstones in 300 consecutive patients who underwent cholecystectomy. The type of stone was correlated with the sex and age of the patients, the size and number of stones, and the presence of acute cholecystitis and gallbladder dysplasia. Cholesterol stone was found in 262 patients (87.3%), black pigment stone in 33 (11%), and brown pigment stone in five (1.7%). All types of stones were more common in females and increased with age. Cholesterol stone was more common in all ages. The number of stones varied from one to 465. Half of the patients had less of five stones. Single stone was found in 65 of 262 patients (24.8%) with cholesterol stone, in one of five patients (20%) with brown pigment stone and none with black pigment stone. The incidence of acute cholecystitis was similar for all three types of stones. There was no diference in the incidence of gallbladder dysplasia in relation to the number; type, and size of stones.1t is concluded that cholesterol stone is the most common type of gallstone. Independent of age and sex of the patients. Although the number of gallstones may vary widely half of the patients subjected to cholecystectomy have less than five stones. Patients with black pigment calculi do not present with single stone.

Resumo em Português:

A cicatrização da pele e do intestino podem ser influenciadas pela elevação da bilirrubina. Com o objetivo de avaliar o possível efeito da icterícia obstrutiva sobre a sutura da pele e de anastomose jejunal, foram estudados 32 ratos, divididos em quatro grupos (n=8) e acompanhados em períodos pós-operatórios de sete e 14 dias. Todos os animais foram submetidos a laparotomia e anastomose jejunal. Os grupos 1 e 2 serviram como controle dos grupos 3 e 4, os quais foram submetidos a ligadura do ducto biliopancreático. Os animais dos grupos 1 e 2 mantiveram o mesmo peso corporal durante todo o período de acompanhamento, enquanto os ictéricos apresentaram uma queda ponderal significativa após sete dias (p<0,05). Não houve diferença na resistência da sutura de pele entre os ratos ictéricos e não-ictéricos. Após duas semanas, a icterícia reduziu a resistência anastomótica jejunal (p<0,01). O exame histológico revelou menor grau de desenvolvimento da fibrose cicatricial nas anastomoses dos ratos ictéricos. Conclui-se que a icterícia obstrutiva pode atuar negativamente sobre a cicatrização tissular. Deve-se ressaltar a importância dos fatores associados à icterícia na gênese desse efeito.

Resumo em Inglês:

Obstructive jaundice may influence skin and smal bowel healing. The effects of obstructive jaundice on skin suture and jejunal anastomoses were assessed on 32 rats, divided into four groups (n=8). The animals were sacrificed at postoperative days seven and 14 days. All animals underwent to laparotomy and jejunal anastomoses. The rats of groups 3 and 4 were also submitted to biliopancreatic duct ligature. The jaundiced rats showed a significant weight loss, in seven days after surgery (p<O,O5). The resistance of jejunal anastomosis decreased after 14 days of jaundice (p<O,O1). However; this condition did not interfere with the skin healing. Histological study showed reduced amount of fibrosis surrounding the anastomoses of the jaundiced rats. The results of the present study suggest that obstructive jaundice interfere negatively with the healing of jejunal anastomoses. However; other factors related to jaundice must be considered as well.

Resumo em Português:

A veia gástrica posterior não é muito citada nos livros de anatomia e nos trabalhos sobre hipertensão porta. Estudou-se sua anatomia, freqüência e desembocadura. Ela foi encontrada em 54% dos casos e, em 100%, desembocava na veia esplênica. Discute-se a vantagem ou não de sua ligadura ou preservação no tratamento cirúrgico da hipertensão porta.

Resumo em Inglês:

The posterior gastric vein has not been mentioned very often neither in anatomy textbooks nor in portal hypertension papers. The authors studied the anatomy, frequency and confluence of this vein because is a huge variety in the presentation of esophageal varices. Twenty-six adult preserved corpses (twenty females and six males) had a wide abdominal incision allowing the dissection of the portal system, identifying the frequency and confluence of its tributaries, notably the posterior gastric vein. The portal vein, in all cases, was formed by the confluence of the superior mesenteric vein with the splenic vein and had a mean length of 6.4 cm. The splenic vein had a mean length of 6.5 cm. The left gastric vein was tributary of the portal vein in 50% of the cases and in 30% of the cases in the splenic vein. The right gastric vein had it's confluence to portal vein in 30 % of the cases and to the splenic vein in 4 %. The inferior mesenteric vein was tributary of the splenic vein in 54% of the cases and in the superior mesenteric vein in 46%. The left gastro-omental vein had its confluence to the splenic vein in 50% of the cases and to the inferior polar vein in 34 %. The middle colic vein had its confluence to superior mesenteric vein in 42% of the cases, to inferior mesenteric vein in 12% and to splenic vein in 8%. The posterior gastric vein was found in 54% of the corpses, and in all cases it was a tributary of the splenic vein, in retropancreatic position, coming from the esophageal-gastric junction. These findings agree with previous papers describing a prevalence of 60% of posterior gastric vein in patients submitted to surgery in portal hypertension, and in all cases, this vein was tributary of the splenic vein. The identification of this vein may influence the treatment, because if left untied during cases of portal-azigos disconnection, they may predispose to postoperative bleeding, but in cases of splenorenal anastomosis may preserve its patency in cases of anastomosis occlusion, or can lead again to postoperative bleeding feeding the esophageal varices. To ligate or not this vein will depends on the surgeon 's experience and common sense. Regarding to previous papers and to this data presented here, the authors believe that the prevalence of this vein is between 50 and 60% in the population.

Resumo em Português:

Nas últimas décadas, diversas alternativas têm sido propostas para o tratamento do trauma esplênico. O presente estudo procurou comparar o tratamento não-operatório e a cirurgia conservadora na lesão esplênica. Foram analisados, retrospectivamente, os prontuários de 136 portadores de trauma esplênico atendidos na Unidade de Emergência do Hospital das Clínicas da FMRPUSP (1986-1995). Foram utilizados o lnjury Severity Score (1SS) e o Organ lnjury Scaling (OIS) para a definição da gravidade dos casos. Os pacientes foram divididos em dois grupos: grupo A (n=32): conservador não operatório e grupo B (n=104): cirurgia conservadora. As médias de idade, em anos, foram semelhantes (A: 20,31 + 12,43 e B: 25,02 + 14,98; p>0,05). Houve predominância do sexo masculino em ambos os grupos. Os dois grupos diferiram quanto à etiologia (p<0,01). A avaliação das médias do ISS não mostrou diferença significativa (A: 14,21 ± 8,67 e B: 19,44 ± 11,33; p>0,05). Ocorreram complicações em 9,37% e 24,03% dos grupos A e B, respectivamente, mas a diferença não foi significativa (p>0,05). A média de permanência hospitalar foi de 6,68 ± 5,65 e 9,24 ± 9,09 dias, grupos A e B, sem diferença significativa (p>0,05). Concluímos, portanto: o tratamento não-operatório e a cirurgia conservadora do trauma esplênico são condutas equivalentes, sendo opções terapêuticas válidas nas lesões esplênicas de menor gravidade.

Resumo em Inglês:

Management of the injured spleen has changed radically over the past decade. The objective of this study was to analyze the nonoperative treatment and the conservative surgery in the splenic trauma. A retrospective study was performed in 136 patients sustaining splenic trauma from Hospital das Clínicas da FMRPUSP (1986-1995). The Injury Severity Score (ISS) and the Organ Injury Scaling (OIS) were determined to evaluate the severity of the cases. Two groups were defined: group A (n=32): nonoperative management and group B (n=104): conservative surgery. The mean age between groups were similar (Group A: 20,31 ± 12,43 years and Group B: 25,02 ± 14,98 years; p>0.05). There was male predominance in both groups. The analysis of the etiology showed difference between the groups (p<0,01). There was no statistical difference in the mean ISS in both groups (A: 14,21 ± 8,67 and B: 19,44 ± 11,33; p>0.05). There was a 9,37% and 24,03% incidence of complications in groups A and B, but it was not statistically significant (p>0,05). The mean length of stay were 6,68 + 5,65 and 9,24 + 9,09 for groups A and B, respectively, with no statistical significance (p>0,05). Conclusion: either conservative surgery or nonoperative treatment are good options in the management of traumatic injuries of the spleen, and both are valid therapeutic choices when dealing with minor splenic injuries.

Resumo em Português:

Trinta e cinco doentes portadores de megacólon chagásico foram operados pela técnica da retocolectomia abdominal com anastomose colorretal mecânica término-lateral durante o período de 1993 a 1997. Vinte (57,14%) doentes eram do sexo feminino e 15 (42,85%) do masculino. A idade variou de 27 a 76 anos, com média de 51 anos. A operação constou de ressecção do segmento dilatado, sepultamento do coto retal na altura da reflexão peritoneal com grampeador, dissecção do espaço retrorretal até o plano dos músculos elevadores e anastomose colorretal mecânica término-lateral posterior. Em quatro (11,42%) doentes a anastomose foi anterior. Em três (8,57%) doentes, o teste de escape da anastomose foi positivo, o que obrigou a complementação manual da sutura em dois (5,71 %) e sutura e ostomia derivativa em um (2,85%). Ocorreram sete (20,00%) complicações pós-operatórias precoces, sendo quatro consideradas relevantes (11,42%) e quatro (11,42%) complicações tardias. Houve um (2,85%) óbito por complicação clínica. Os doentes submetidos a colostomia foram reoperados para fechamento da mesma sem intercorrências. A totalidade dos doentes apresenta hábito intestinal normal. Não houve referências a alterações gênito-urinárias, nem a incontinência fecal. A anastomose foi tocada ou visibilizada em todos os pacientes examinados, durante o seguimento ambulatorial. Não houve casos de fecaloma no coto retal. Embora os resultados iniciais sejam bastante satisfatórios, é necessário maior tempo de observação para se avaliar a possibilidade de recidiva.

Resumo em Inglês:

Thirty five patients with chagasic megacolon were operated on by the technique of recto-colectomy with colo-rectal mechanical end-to-side anastomosis, anterior or posterior during the period of 1993 to 1997. Twenty (57.14%) patients were female and 15 (42.85%) male. The age ranged from 27 to 76 years, with a mean of 51years. The operation consisted of resection of the dilated colon, closure of the rectal stump at the level of the peritoneal reflexion, dissection of the rectrorectal space down to the level of the levator ani and posterior end to side colo-rectal mechanical anastomosis. Four (11.42%) patients had the anastomosis made anteriorly. Three (8.57%) patients had a positive test of the anastomosis integrity and demanded suture in two (5.71%) and suture and ostomy in one (2.85%). There were seven postoperative early complications, four (11.42%) considered important and four late complications. There was one (2.85%) death due to clinical complication. Patients that underwent colostomy were reoperated in order to close it with no problems. The totality of patients has normal bowel function. There were no complaints of sexual, urinary disturbances or fecal incontinence. The anastomosis was examined in all patients. There was no case of fecaloma in the rectal stump. Although the initial results are good, a long follow up is necessary to evaluate the possibility of recurrence.

Resumo em Português:

É apresentada uma conduta cirúrgica para o descolamento do duodeno nas ressecções gastroduodenais por úlcera terebrante na cabeça do pâncreas. Constituem os fundamentos dessa tática a mobilização retrógrada adequada da segunda porção do duodeno por meio da manobra de Kocher, a secção oblíqua do duodeno na altura da borda distal do nicho ulceroso e a introdução, pelo cirurgião, do seu dedo indicador na luz da víscera para palpar a papila duodenal maior. Essa medida permite encontrar o plano de clivagem para separar a parede duodenal da cabeça do pâncreas e afastar o risco de lesão das vias biliares e pancreáticas. O duodeno, assim preparado, possibilita sua utilização para eventual anastomose gastroduodenal ou sua exclusão quando se deseja proceder a gastrojejunostomia.

Resumo em Inglês:

Beginning in the 1970s, many duodenal ulcers have been adequately managed using H2 receptor blockers or proton pump inhibitors associated to antimicrobial agents. However in the bleeding penetrating duodenal ulcer when the endoscopic treatment is lacking, the severe character of the hemorrhage and the frequence of the recurrence sometimes impose a radical surgery as early as possible, in spite of technical difficulties. Considering these facts, a surgical approach to the duodenal dissection during the gastroduodenectomy for penetrating ulcers is presented. This maneuver basically consist of (1) the adequate retrograde liberation of the descending portion of duodenum, (2) the oblique section of the duodenum at the lower border of the ulcer and (3) the introduction of the surgeon's forefinger into the duodenal lumen in order to facilitate the wall liberation from the pancreas achieved through a blunt dissection with a fine scissor or a Halsted forceps. The duodenal stump is now prepared for a gastroduodenal anastomosis or for closure by suture previously to a gastrojejunostomy. This technique have been used by one of us for many times with fairly good results.

Resumo em Português:

A esofagite de refluxo associada ao epitélio de colunar do esôfago predispõe ao adenocarcinoma, cuja incidência vem aumentando nos últimos anos. Entre 1976 e 1993, os autores trataram 11 pacientes com adenocarcinoma primário do esôfago. Em dois casos, a neoplasia desenvolveu-se em epitélio colunar ectópico no esôfago cervical e torácico. Nos demais casos, ocorreu no terço distal do esôfago em epitélio colunar de Barrett, em pacientes com sintomas clínicos de esofagite de refluxo, dos quais sete eram portadores de hérnia de hiato e refluxo gastroesofágico previamente documentados. Nove pacientes foram submetidos a esofagectomia transiatal com esofagogastroplastia, um foi submetido a esofagectomia distal com interposição de jejuno e o último a esofagogastroplastia retroestemal sem esofagectomia. A exceção de três pacientes, os demais tiveram operações consideradas curativas. Cinco doentes encontravam-se em estádios mais iniciais, ainda sem comprometimento linfonodal. Não houve mortalidade operatória, sendo que as principais complicações foram a fístula da anastomose esofagogástrica e a abertura da cavidade pleural, ambas ocorrendo em dois pacientes. A sobrevida média dos pacientes foi de 40,5 meses. Três pacientes permanecem vivos e sem evidência de doença (estádio 0, I e IIA) com 64, 94 e 117 meses de seguimento. Concluiu-se que a esofagectomia neste tipo de tumor é um procedimento seguro e que a sobrevida a longo prazo é possível quando os tumores em estadio inicial são tratados adequadamente.

Resumo em Inglês:

Esophagitis associated with Barretts esophagus is a recognized predisponent factor for the development of adenocarcinoma. its incidence has been raising through the last years. Between 1976 and 1993, eleven patients with primary adenocarcinoma of the esophagus were treated. In two cases, the neoplasia occurred in an aberrant gastric mucosa in the cervical and thoracic esophagus. in the remaining cases, the tumor occurred in the distal third of the organ. in columnar-lined (Barretts) esophagus, in patients with hiatal hernia and gastroesophageal refluxo Nine patients were submitted to transhiatal esophagectomy. one to distal esophagectomy with interposition of jejunum. and one to retrosternal esophagogastroplasty without esophagectomy. All but three patients had curative operations. Five patients had early stage disease, without limphonode involvement. There was no operative mortality and the main complications were anastomotic leackage and openning of pleural cavity, both of them occurring, in two patients. The average survival of these patients was 40.5 months. Three patients remain alive and with no evidence of recurrence (Stage 0, I and IIA), with a follow-up of 64, 94 and 117 months. Patients with gastroesophagic reflux and Barretts esophagus must be properly treated and they need endoscopic surveillance for the evaluation of progressive dysplasia or adenocarcinoma. The authors conclude that esophagectomy is a safe procedure and long term survival is possible when these esophageal tumors are treated in the early stages.

Resumo em Português:

A maioria dos retalhos utilizados na reconstrução dos grandes defeitos pós-tratamento cirúrgico isolado ou associado à radioterapia no câncer da cabeça e pescoço levou os autores a estudar a viabilidade do RMF em 14 pacientes, atendidos no Serviço de Cabeça e Pescoço do Hospital Celso Pierro, PUCCAMP, Campinas. Todos eram portadores de lesões epidermóides avançadas no estádio IV, localizadas na boca (dez), hipofaringe (dois), laringe (um) e pescoço (um). Através do teste exato de Fisher (p< 0,05), aferiu-se a existência ou não da relação da viabilidade do RMF com a idade, estado nutricional, tratamento prévio. Nestes 14 pacientes, foram empregados 16 retalhos, 13 deles viáveis (81,2%) e três (18,8%) com necrose total, não havendo associação entre a viabilidade e a necrose e a idade (p=1,0). Quanto à relação com o tratamento prévio com quimioterapia (três casos) e radioterapia (dois casos), estes não foram significantes (p=0,547).

Resumo em Inglês:

The great incidence of advanced squamous cell carcinoma of the mouth, pharynx, larynx and neck, justifies the extensive resections that are carried out by the authors at the Head and Neck Service of Hospital Celso Pierro PUCCAMP - São Paulo. Major pectoralis myofascial flap were used to manage 14 patients with advanced head and neck squamous cell carcinoma of the mouth (ten cases), pharynx (two cases); larynx (one case) and neck (one case). There was no complications in 81.2% and in 18.8% total necrosis of the flap was observed. We conclude that viability, age and necrosis or fibrosis were not associated with the success of this procedure (p=1.0), and previous treatment (chemoradiotheraphy and or radiotherapy alone) had no significant relation with flap viability (p=0.547).

Resumo em Português:

Os tumores neuroendócrinos (TNE) já foram considerados raridades. Atualmente, através de novas técnicas para seu reconhecimento, tem-se identificado um número crescente destas neoplasias, sendo possível estratificá-las em subgrupos, expandindo o espectro dos neoplasmas neuroendócrinos e sua importância na prática cirúrgica atual. A imunocitoquímica, a dosagem de peptídeos e os modernos métodos de imagem proporcionam informações imprescindíveis para um diagnóstico acurado e o tratamento adequado. Este artigo tem por objetivo revisar aspectos referentes aos tumores neuroendócrinos do trato gastrointestinal relativos à história, fisiopatologia, classificação atualizada, diagnóstico e tratamento.

Resumo em Inglês:

Neuroendocrine tumors were previously considered rarieties. However with the new techniques for its recognition, they have been in a identified growing number of cases, making it possible to stratify them in subgroups. The imunocitochemistry peptide dosage and modern imaging techniques provide essential informations from acurate diagnosis and appropriate treatment. The objective of this review is to discuss the aspects of neuroendocrine tumors of the gastrointestinal tract.

Resumo em Inglês:

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.

Resumo em Inglês:

Disphagia is a very common complaint among patients seeking a gastroenterologists. Esophageal motility disorder is a frequent finding, at times associated with pulsion diverticula. We present a case of a 68 year old female patient with thoracic pain and double epiphrenic diverticula. The upper gastrointestinal tract examination revealed two epiphrenic diverticula, one with 6-7 cm and the other measuring 2 cm, located 30 cm from the dental arcade. She underwent surgical treatment to remove the larger diverticula, a long esophageal myotomy and a Belsey-Mark IV antireflux technique. She presented an uneventful recovery and is doing well I8 months following surgery.

Resumo em Inglês:

A rare case of blunt traumatic abdominal hernia is presented in which jejunal loops herniated through the abdominal wall. The patient had a serious motor vehicle accident seven years ago, while wearing the seat belt. He developed a traumatic hernia in the anterior lateral abdominal wall, which was operated, and relapsed after some months. The patient was reoperated and we observed the unattachment of the anterior lateral abdominal musculature from the ilium crest. After the hernial sac treatment, the defect was solved with the use of a polypropylene mesh. The postoperative evolution was good and four months later there were no signs of recurrence. Traumatic abdominal hernia remains a rare clinical entity, despite the increase in blunt abdominal trauma. Traumatic abdominal wall hernia falls into two general categories: small lower quadrant abdominal defects, typically the result of blunt trauma with bicycle handlebars, and larger abdominal wall defects related to motor vehicle accidents. The diagnosis may be often established by the physical examination alone. Conventional radiology and computerized tomography usefulness have been proved. In the vast majority of cases, early repair is recommended. The appropriate treatment is the reduction of the herniated bowel into the abdomen, the debridment of nonviable tissues, and a primary tension free closure of the detect.

Resumo em Inglês:

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.