Resumo em Português:

OBJETIVOS: A isquemia tem sido utilizada na cirurgia hepática desde o início do século. Embora possibilite a diminuição da perda sangüínea durante as ressecções e a manutenção do órgão à espera de um transplante, a ausência de perfusão traz como conseqüência um dano ao órgão, que se amplifica por ocasião da sua reoxigenação. A N-Acetilcisteína é uma droga capaz de repor os estoques celulares de glutationa, um antioxidante fundamental no controle das lesões resultantes do restabelecimento da perfusão sangüínea, esperando-se dessa forma que diminua a lesão acima descrita. Com o propósito de avaliar a capacidade da N-Acetilcisteína reduzir o dano hepático, utilizou-se um modelo murino de isquemia e reperfusão normotérmica. MÉTODO: Foram utilizados vinte ratos Wistar fêmeas, divididos em dois grupos. No grupo tratado, 400mg/kg de N-Acetilcisteína foram administrados pela via intravenosa, 15 minutos antes do clampeamento do pedículo do lobo esquerdo por 90 minutos. No grupo controle foi administrado o volume equivalente de solução fisiológica. Foi estabelecido um período de quatro horas de reperfusão, após o qual os animais foram sacrificados para a realização de análise histopatológica do lobo esquerdo com coloração de Hematoxilina-Eosina. A lesão tecidual foi quantificada quanto à presença de congestão, esteatose e necrose. RESULTADOS: O estudo evidenciou a capacidade de a N-Acetilcisteína diminuir significativamente a congestão. Não houve diferenças quanto à presença de esteatose e necrose. CONCLUSÃO: Os resultados obtidos permitem-nos concluir que o uso prévio da N-Acetilcisteína nos processos de isquemia e reperfusão, em normotermia, é capaz de diminuir a congestão hepática. A N-Acetilcisteína não diminui a presença de esteatose e necrose.

Resumo em Inglês:

BACKGROUND: Ischemia has been used in hepatic surgery since the beginning of the century. Its use results in less blood loss during hepatic resections and allow organ preservation while waiting for a transplant. Nevertheless, the lack of perfusion causes liver injury, worsen by the reoxygenation of the organ. N-Acetylcysteine is a drug capable of restoring cellular glutatione levels, essential to control reperfusion injury. Therefore, N-Acetylcysteine could be useful to lessen liver damage. To evaluate N-Acetylcysteine ability to reduce hepatic damage, a murine model of normothermic ischemia and reperfusion was used. METHODS: Twenty female Wistar rats were divided in two groups. In the first group, N-Acetylcysteine 400mg/kg was given intravenously fifteen minutes before the left hepatic lobe clamping. The clamp was kept in place for ninety minutes. In the control group, normal saline was given in an equivalent volume. After four hours of reperfusion, animals were killed and left lobes were submitted to histopathological analysis stained with Hematoxilin-Eosin. Specimens were evaluated for congestion, steatosis and necrosis. RESULTS: Analysis showed N-Acetylcysteine capability of significantly decrease hepatic congestion. There was no difference in regard of steatosis and necrosis. CONCLUSION: We concluded that previous N-Acetylcysteine administration reduces congestion in normothermic ischemia-reperfusion of the liver lobe. The drug does not reduce steatosis or necrosis.

Resumo em Português:

OBJETIVO: Este estudo tem por objetivo avaliar a relação entre o tamanho do tumor, duração da sintomatologia e a evolução de pacientes com carcinoma epidermóide de língua e soalho bucal. MÉTODO: foram avaliados retrospectivamente 226 pacientes submetidos à ressecção de tumor primário de língua e/ou soalho da boca em combinação com esvaziamento cervical. Foi estimado o crescimento mensal do diâmetro tumoral médio (raiz quadrada da superfície/número de meses de evolução) e relacionado com a presença de metástases e recidiva local. A sobrevida livre de doença foi avaliada em relação ao tamanho do tumor e à duração dos sintomas. RESULTADOS: 16% dos tumores T1 e T2 e 11% dos tumores T3 e T4 apresentaram tempo de sintomatologia igual ou inferior a um mês. A mediana de crescimento do diâmetro tumoral foi de 0,81cm/mês. Não houve diferença no crescimento tumoral entre os pacientes pN+ ou pN0; 30 pacientes desenvolveram recidiva local, sendo 15 com crescimento tumoral menor do que 0,82cm/mês e 15 no grupo com crescimento ³ 0,82cm/mês. CONCLUSÕES: A taxa de crescimento tumoral não se relacionou com o intervalo livre de doença nos pacientes que apresentaram recidiva local. Os pacientes com tumores menos extensos e menor duração dos sintomas apresentaram maior sobrevida livre de doença. O tempo de sintomatologia e a estimativa de crescimento tumoral não apresentam valor prognóstico nos carcinomas epidermóides de língua e soalho oral.

Resumo em Inglês:

BACKGROUND: The objective of this study is to evaluate the real impact of tumor size, on symptoms and evolution of patients with squamous cell carcinoma of the tongue and floor of the mouth. METHODS: after 226 neck dissections plus primary resection, were estimated the monthly growing of the medium tumor diameter (square root of surface/number of months) and related with metastasis presence and local recurrence. The free disease survival were analysed in relation to tumor syze and complaints length. RESULTS: 16% of T1 and T2 and 11% of T3 and T4 tumors growth of tumoral diameter were 0,81cm/month, without differences between pN+ and pN0 patients; 30 patients with local recurrence, being 15 with tumoral growing less than 0,82cm/month and 15 with more than 0,82cm/month. CONCLUSIONS: The neoplasia growing were not related with free disease survival in patients with local recurrence, and those with less extensive tumors and complaints time present a greater free disease survival. The time complaints and the tumoral growing were not prognostic in squamous cell carcinoma of tongue and flon of the mouth.

Resumo em Português:

OBJETIVO: Avaliar os resultados da derivação esofagogástrica no câncer avançado do esôfago. MÉTODO: Foram estudados de forma retrospectiva 24 pacientes com carcinoma epidermóide de esôfago nos estádios III (66,66%) e IV (33,34%), submetidos à derivação esofagogástrica através da construção do tubo gástrico isoperistáltico da grande curvatura pela técnica de Postlethwait. RESULTADOS: Quanto à morbidade e mortalidade, os pacientes de média etária de 41,8 anos e linfócitos acima de 1.500/mm³ demonstraram taxas de complicações pós-operatórias inferiores àqueles com média de 54,09 anos. A fístula da anastomose, embora seja considerada comum (15 casos - 62,50%), apresentou evolução benigna e ocluiu espontaneamente em 14 casos. Não houve qualquer tipo de complicação cirúrgica pós-operatória em cinco casos (20,83%), o tempo médio cirúrgico foi de 285,77 minutos, e a mortalidade operatória de sete casos (29,17%). A sobrevida foi 4,19 meses. CONCLUSÕES: Em vista da ocorrência de complicações, que determinam altas taxas de morbidade e mortalidade, o tubo gástrico isoperistáltico é um método de tratamento cirúrgico que deve ser dirigido a pacientes selecionados, em especial àqueles com número alto de linfócitos e idade mais baixa.

Resumo em Inglês:

BACKGROUND: Evaluation of esophageal gastric derivation with isoperistaltic gastric tube in advanced esophageal cancer. METHOD: Twenty-four patients presenting esophageal squamous cell carcinoma classified as stage III (66.66%) and IV (33.34%), were submitted to an esophagus gastric derivation through the construction of an isoperistaltic gastric tube of the large flexure, using the Postlethwait's technique. RESULTS: Patients with a mean age of 41.8 years and lymphocytes above 1,500/mm³, showed less postoperative disorders than those with a mean age of 54.09 years. Anastomotic fistula, although considered normal in 15 cases (62.50%), presented a benign evolution and spontaneously healed in 14 cases. No postoperative complications were observed in 5 cases (20.83%) and mean surgical time was 285.77 minutes. Survival rate was 4.19 months. CONCLUSIONS: In spite of high morbidity and mortality rates the isoperistaltic tube is a surgical procedure that must be suggested to well selected cases, specially those with a great rate of lymphocytes, low mean age and in cases where anastomosis fistula has a benign evolution.

Resumo em Português:

OBJETIVO: "Nanismo esplênico" é condição clínica decorrente de processo imunitário relacionado ao baço e tem como tratamento preconizado a esplenectomia total. Seguindo uma linha de pesquisa voltada ao estudo da esplenectomia subtotal em diferentes afecções, o objetivo do presente trabalho foi avaliar o crescimento somático de pacientes portadores deste hipodesenvolvimento esplenomegálico, submetidos à esplenectomia subtotal com preservação do pólo superior esplênico irrigado apenas pelos vasos esplenogástricos. MÉTODO: Quatro pacientes masculinos (14, 14, 16 e 17 anos) com esplenomegalia (três de etiologia esquistossomática e um com cirrose auto-imune) e retardo do desenvolvimento somático e sexual foram submetidos à esplenectomia subtotal. As indicações para cirurgia foram sangramento de varizes do esôfago e pancitopenia. RESULTADOS: Em todos os casos houve retomada do crescimento e após um ano eles já se encontravam dentro da faixa de desenvolvimento somático e sexual compatível com a idade. CONCLUSÃO: O hipodesenvolvimento esplenomegálico não é decorrente da presença do baço, mas de seu crescimento; a esplenectomia subtotal é um procedimento adequado para tratar o retardo de desenvolvimento somático e sexual por esplenomegalia.

Resumo em Inglês:

BACKGROUND: According to the literature, splenic dwarfism is an immune disease due to the splenic presence and its treatment is total splenectomy. Following a line research related to subtotal splenectomy, the aim of this study was to verify whether a conservative procedure on the spleen by preserving the upper splenic pole vascularized only by the splenogastrics vessels is an adequate procedure to treat splenic dwarfism. METHOD: Four male teenagers (14, 14, 16 and 17 years old) with splenomegaly (3 due to schistosomiasis and other due to auto-immune cirrhosis) presented growth and sexual hypodevelopment and were submited to subtotal splenectomy. Surgical indications were oesophageal and gastric variceal haemorrhages and pancytopenia. RESULTS: The four boys increased their growth reaching in one year adequate somatic and sexual development. CONCLUSION: We conclude that dwarfism is not due to the presence of the spleen, but rather due to splenomegaly and subtotal splenectomy should be considered for the treatment of splenomegalic growth and sexual hypodevelopment.

Resumo em Português:

OBJETIVO: Demonstrar a eficiência da redução de grandes onfaloceles utilizando o âmnio como "silo". MÉTODO: Doze pacientes com onfaloceles gigantes submetidos à redução progressiva pela inversão do âmnio. RESULTADOS: Obtida redução completa entre cinco e dez dias, sem necessidade de prótese, em dez pacientes. Foram colocados dois "silos" por ruptura do âmnio durante a redução, com um óbito por septicemia. CONCLUSÕES: Apesar da casuística ser pequena, o método se mostrou confiável e eficaz no tratamento definitivo das grandes onfaloceles.

Resumo em Inglês:

BACKGROUND: To study the viability of using the amnion as a silo to squeeze the content of large omphaloceles. METHOD: Twelve newborns had their omphaloceles squeezed using a modified amnion inversion procedure. RESULTS: Ten patients had primary omphalocele closure after 5 to 10 days of amnion squeezing only. Two patients required a silo implantation secondary to amnion tearing, with one death secondary to sepsis. CONCLUSIONS: Even with a small number of patients the method of amnion squeezing seems to be safe and effective in the management of large omphaloceles

Resumo em Português:

OBJETIVO: Comparar os inventários da cavidade abdominal, quanto à visibilização das estruturas anatômicas, realizadas pelos métodos videolaparoscópico e laparotômico, no trauma abdominal. MÉTODO: De novembro de 2001 a fevereiro de 2002, 25 pacientes foram submetidos ao protocolo de pesquisa, sendo 21 do sexo masculino e quatro do feminino. A idade média foi de 30,88 anos, variando de 18 a 63. O inventário videolaparoscópico foi realizado de forma padronizada e seqüencial. Em seguida, todos os pacientes foram laparotomizados e o inventário refeito com os mesmos critérios. As estruturas e vísceras abdominais foram classificadas em visualizadas, parcialmente visualizadas e não visualizadas. RESULTADOS: No inventário videolaparoscópico, o lobo esquerdo do fígado, as cúpulas diafragmáticas, a vesícula biliar, a parede posterior da bexiga, o fundo de saco anterior e a face interna da parede abdominal foram completamente visualizadas em todos os casos. As demais estruturas e vísceras intra-abdominais foram completamente visualizadas em percentuais que variaram de 25% a 76%. O inventário videolaparoscópico apresentou sensibilidade de 45,45%, especificidade de 100%, valor preditivo positivo de 100% e valor preditivo negativo de 20%. O inventário laparotômico identificou 78 injúrias e o videolaparoscópico 56. CONCLUSÕES: O inventário videolaparoscópico no trauma abdominal não é eficiente para a visualização e diagnóstico das lesões intra-abdominais. Entretanto é confiável nas dúvidas de penetração para a cavidade abdominal, no diagnóstico das lesões diafragmáticas e tóraco-abdominais, e para excluir lesões da parede anterior do esôfago, estômago e duodeno, parede posterior da bexiga e da vesícula biliar.

Resumo em Inglês:

BACKGROUND: To compare the evaluation of the abdominal cavity by videolaparoscopic and laparotomic methods, in patients sustaining abdominal trauma. METHOD: From November of 2001 to February of 2002, 25 patients were studied, being 21 males and four females. Average age was 30.88 years, varying from 18 to 63. The videoendoscopic evaluation was carried through in a standardized and sequential form. After that, all the patients were laparotomised and the evaluation remade with the same criteria. Abdominal structures and viscera were classified as visualized, partially visualized, not visualized and non-existent. RESULTS: In videolaparoscopic evaluation, the left lobe of the liver, the diaphragmatic domes, the gallbladder, the posterior wall of the bladder, anterior Douglas' cul-de-sac and the internal face of the abdominal wall were fully visualized in all cases. The others intra-abdominal structures and viscera were completely visualized in percentages that varied from 25% to 76%. Videolaparoscopic evaluation presented sensitivity of 45.45%, specificity of 100%, positive predictive value of 100% and negative predictive value of 20%. Laparotomic evaluation identified 78 injuries and videolaparoscopy 56. CONCLUSIONS: Videolaparoscopic evaluation in abdominal trauma is not effective in the visualization and diagnosis of intra-abdominal injuries. However it is sufficiently trustworthy in cases of doubts of penetration of the abdominal cavity, in the diagnostic of diaphragmatic and toraco-abdominal injuries and to exclude injuries of the anterior esophagus, stomach and duodenum wall, posterior wall of the bladder and gallbladder.

Resumo em Inglês:

We intend to discuss the main controversies involved in the diagnosis of gastroesophageal reflux and the necessity of a special method to feed severe neurologically impaired children, considering the implications of those circumstances in Brazilian families. Modern literature was reviewed, relating to diagnostic methodologies and their limitations, surgical methods, complications and resolution of the symptoms. There are controversies not yet solved about alimentary problems in the neurologically impaired children, specially concerning the presence of gastroesophageal reflux and respiratory disease. Familiar and social consequences of both primary neurological and secondary respiratory and nutricional disease are essential to consider. The incidence of gastroesophageal disease is extremely high in neurologically impaired children, with a high morbimortality and frequent respiratory manifestations. Surgical treatment offers high risks in case of associated complex congenital cardiac malformations. Alimentary gastrostomy and fundoplication offer good results concerning the incidence of respiratory problems and less hospitalizations for those patients.

Resumo em Inglês:

The authors report the surgical procedure in two patients with pseudomyxoma peritonei, histologically considered as mucinous adenocarcinoma. In both patients, intestinal loops and other visceras were blocked and it was not possible to localize the tumor's origin. There was, in both cases, a great volume of mucinous ascitis. In the first patient a laparotomy was performed and a drainage by a five centimeters peritoneostomy in the abdominal upper left quadrant. In the second just a peritoneostomy was performed in the same location. The sequential irrigation of the abdominal cavity controlled the ascitis in a few days. Certainly this approach avoided a second procedure to clean the mucinous ascitis.

Resumo em Inglês:

A 32-year-old woman was referred to our institution for a pelvic mass. She was asymptomatic and was found to have a mass on rectal examination. Magnetic resonance showed a large solid-cystic mass and the patient underwent complete surgical excision with pathologic findings suggesting retrorectal cyst-hamartoma. Tailgut cysts (or retrorectal cystic hamartomas) are rare congenital lesions settled in the retrorectal (presacral) space. They are made up of cysts lined by multiple types of epithelium, often predominantly mucin-secreting. The lesion requires complete surgical excision to prevent complications of recurrence, infection or carcinomatous degeneration.

Resumo em Inglês:

Pyogenic hepatic abscess by a foreign body is a rare disease and its diagnosis is habitually made during necropsy. The authors present a case of a woman operated because of a pyogenic hepatic abscess, in the interior of which bristle made of material of vegetable origin were encountered and identified in the laboratory as the principal rib of a leaf, known in Brazil as piaçava. The hepatic abscess was drained and the patient was discharged. The probable mechanism for the formation of the hepatic abscess consisted of the accidental ingestion, perforation of the intestines and penetration in the liver.

Resumo em Inglês:

We report a rare cause of pyloric stenosis caused by migration of surgical clips into a duodenal ulcer following laparoscopic cholecystectomy. Even after endoscopic removal of the clips the inflammatory reaction during the healing process caused a stenosis of the pylorus that eventually required a truncal vagotomy and gastroenterostomy.

Resumo em Inglês:

Videolaparoscopic surgery has been used for treatment of almost all surgical abdominal diseases, mainly where there are no large ressections, or operative field is limited. In these situations, laparoscopic surgery has the advantages of less morbidity, quick recovery and good cosmetic results. Bezoars removal, or its mobilization, is probably included in these possible proceedings. Three non-laparotomic procedures were described: 1. endoscopic-laparoscopic; 2. videolaparoscopy and mobilization of intestinal bezoar to the cecum; 3. laparoscopy and gastrotomy for bezoar removal, through suprapubic incision or the umbilical punction. There have been only two publications describing the videolaparoscopic method for bezoar removal, and the methods applied can be complications or morbidity related. We describe one case where the applied technique is simple and easy to perform, time saving and probably less complications-related. This technique, with four trocars, utilized a plastic bag besides the stomach to be opened, followed by gastrotomy, bezoar removal and immediate introduction in the plastic bag, suture of gastrotomy and removal through the left subcostal trocar. This technique was feasible and easy to perform, with short operative time, and there were no intra or post-operative complications; the patient was discharged in the second post-operative day, and is without further problems after one year follow-up. We believe that this could be an adequate technique to perform laparoscopic gastric bezoar removal, and the rigid sequence of operative events allows a quick procedure, with minimal contamination. The videolaparoscopy seems to be an adequate access to surgical treatment of gastro-intestinal bezoars, with or without obstruction, and should be the ellected the procedure of choice to begin the surgical treatment, with convertion to laparotomy in case of any intra-operative adversity.