Larger amounts of nitrite and nitrate-reducing bacteria in megaesophagus of Chagas' disease than in controls.

In the megaesophagus of Chagas' disease, chronic esophagitis is caused by stasis of swallowed food and saliva. In this environment, the overgrowth of aerobic and anaerobic bacteria, including nitrate-reducing bacteria, is observed. The reduction of nitrate into nitrite by the action of these bacteria has been associated with the formation of volatile nitrosamines in different situations of gastric bacterial overgrowth. We have hypothesized that this phenomenon could occur in the esophageal lumen of patients with megaesophagus. To evaluate the concentration of nitrite, the presence of volatile nitrosamines and the concentration of nitrate-reducing bacteria in the esophageal lumen of patients with non-advanced megaesophagus of Chagas' disease and in a group of patients without esophageal disease. Fifteen patients with non-advanced megaesophagus [megaesophagus group (MG)] and 15 patients without any esophageal disease [control group (CG)] were studied. Saliva samples were taken for nitrate and nitrite quantitative determination and esophageal stasis liquid samples were taken for nitrate and nitrite quantitative determination, volatile nitrosamines qualitative determination and reductive bacteria quantitative determination. MG and CG were equivalent in nitrate and nitrite saliva concentration and in nitrate esophageal concentration. Significant difference was found in nitrite (p = 0.003) and reductive bacteria concentration (p < 0.0001), both higher in MG. Volatile nitrosamines were identified in three MG patients and in none of the CG patients, but this was not significant (p = 0.113). There is a higher concentration of reductive bacteria in MG, responsible for the rise in nitrite concentration at the esophageal lumen and, eventually, for the formation of volatile nitrosamines.

An evaluation of gastric scintigraphy pre- and postpyloroduodenal peptic stenosis dilation.

BACKGROUND: The usual treatment of pyloroduodenal peptic stenosis has been mainly surgical, through pyloroplasty or gastric resection, with or without vagotomy. Since the first description of treatment for this peptic complication by endoscopic balloon dilation perfomed by Benjamin in 1982 [2], this procedure has become a therapeutic option in association with the medical treatment of peptic disease. The aim of this study is to evaluate the results involving clinical, endoscopic, and gastric emptying scintigraphy parameters. METHODS: Between August 1998 and February 2000, 20 patients with pyloroduodenal stenosis refractory to conservative treatment were treated at the Gastrointestinal Endoscopy Unit of the University of São Paulo Medical School. All patients who presented clinical manifestations of pyloroduodenal stenosis underwent upper gastrointestinal endoscopy to confirm peptic stenosis. Biopsy of the narrowing for the confirmation of a benign disease and gastric biopsy for Helicobacter pylori detection were performed. The treatment consisted of dilation of the stenosis with type TTS (Through The Scope) hydrostatic balloon under endoscopic control, treatment of Helicobacter pylori infection, and gastric acid suppression with oral administration of proton pump inhibitor. All patients, except one who was excluded from this study, were submitted to a clinical endoscopic assessment and gastric emptying evaluation by ingestion of (99m)Tc before and after the treatment. Endoscopic evaluation considered the diameter of the stenotic area before and after treatment. A scintigraphic study compared the time of gastric emptying before and after balloon dilation. RESULTS: Nineteen patients completed treatment by hydrostatic balloon dilation. Clinical symptoms such as bloating (p < 0.0001), epigastric pain (p = 0.0159), gastric stasis (p < 0.0001), and weight gain (p = 0.036) showed significant improvement. The diameter of the stenotic area increased significantly (p < 0.01) after the dilation treatment as well as a better gastric emptying of (99m)Tc (p < 0.0001). CONCLUSION: The dilation of the peptic pyloroduodenal stenosis using a hydrostatic balloon is a safe and effective procedure. The evaluation with gastric scintigraphy by ingestion of (99m)Tc is an effective method of assessment for the improvement of gastric function, because its results corresponded to the clinical improvement after endoscopic treatment.

Lipid peroxidation in bariatric candidates with nonalcoholic fatty liver disease (NAFLD) -- preliminary findings.

BACKGROUND: Pathogenesis of nonalcoholic fatty liver disease (NAFLD) remains incompletely known, and oxidative stress is one of the mechanisms incriminated. The aim of this study was to evaluate the role of liver oxidative stress in NAFLD affecting morbidly obese patients. METHODS: 39 consecutive patients with BMI >40 kg/m2 submitted to Roux-en-Y gastric bypass were enrolled, and wedge liver biopsy was obtained during operation. Oxidative stress was measured by concentration of hydroperoxides (CEOOH) in liver tissue. RESULTS: Female gender was dominant (89.7%) and median age was 43.6 +/- 11.1 years. Histology showed fatty liver in 92.3%, including 43.6% with nonalcoholic steatohepatitis (NASH), 48.7% with isolated steatosis and just 7.7% with normal liver. Liver cirrhosis was present in 11.7% of those with nonalcoholic steatohepatitis. Concentration of CEOOH was increased in the liver of patients with NASH when compared to isolated steatosis and normal liver (0.26+/- 0.17, 0.20+/- 0.01 and 0.14+/- 0.00 nmol/mg protein, respectively) (P < 0.01). Liver biochemical variables were normal in 92.3% of all cases, and no difference between NASH and isolated steatosis could be demonstrated. CONCLUSIONS: 1) Nonalcoholic steatosis, steatohepatitis and cirrhosis were identified in substantial numbers of morbidly obese patients; 2) Concentration of hydroperoxides was increased in steatohepatitis, consistent with a pathogenetic role for oxidative stress in this condition.

Severe protein-calorie malnutrition after bariatric procedures.

BACKGROUND: Serious nutritional complications after Roux-en-Y gastric bypass (RYGBP) are infrequent. In a retrospective study of patients operated during a 68-month period, malnutrition was investigated to analyze circumstances associated with nutritional failure. METHODS: In 236 consecutive RYGBPs, 11 patients with severe malnutrition were identified (4.7%) with age 45.1 +/- 10.6 years (10 females/1 male) and initial BMI 54.6 +/- 8.4 kg/m(2). RESULTS: In these 11 patients, the derangement was diagnosed 17.9 +/- 15.8 months after RYGBP, following defined events in 63.6% (gastric stenosis, associated diseases ) or mostly exaggeration of expected symptoms in 36.4% (vomiting without endoscopic abnormalities). BMI then was 31.4 +/- 8.6 kg/m(2) (42.5 +/- 9.9% total reduction, or 2.4 +/- 2.1% decrease/month), and serum albumin and hemoglobin were 24.0 +/- 8.2 g/L and 97.0 +/- 23.0 g/L respectively. Edema was present in 45.4% (5/11), hospitalization was required in 54.5% (6/11), and 18.2% (2/11) eventually died. CONCLUSIONS: Serious malnutrition was unusual but not exceedingly rare in this series. Exogenous precipitating factors were clearly identified in 63.6% of the patients. Careful clinical and nutritional follow-up is recommended to prevent these uncommon but potentially dangerous complications.

Prognostic significance of intraperitoneal free cancer cells obtained by laparoscopic peritoneal lavage in patients with gastric cancer.

Laparoscopy is a safe and useful method for examining the local extent and regional spread of disease in patients with gastric cancer. Peritoneal dissemination remains a frequent type of recurrence after surgical treatment. The aim of this study was to determine the prognostic value of intraperitoneal free cancer cells (IFCCs) detected by laparoscopic peritoneal lavage. Forty-nine patients with advanced gastric cancer underwent laparoscopy with cytologic examination for staging. Peritoneal lavage was performed when ascites was not present. Aspirated fluid from the peritoneal cavity was centrifuged and subjected to cytologic examination using Giemsa and Papanicolaou staining methods. Patients were surgically treated and followed for a minimum of 5 years. IFCCs were detected in 41% of the patients. In eight cases (16.3%) laparoscopy revealed carcinomatosis and/or multiple liver metastases, so laparotomy was not performed. Patterns of recurrence after curative resection included the following: peritoneal (n = 3), local (n = 4), liver (n = 1), and other (n = 1). All patients who tested positive for IFCCs had peritoneal recurrence. The absence of IFCCs was associated with improved overall survival (21 months for a 95% confidence interval of 7.4 to 34.6 vs. 4 months for a 95% confidence interval of 2.4 to 5.6). Overall survival adjusted for type of resection also demonstrated a favorable outcome for patients who were negative for IFCCs. The following conclusions were drawn: (1) laparoscopic peritoneal lavage cytology may be useful in identifying patients at high risk for peritoneal relapses and may alter treatment, and (2) lFCCs provide additional prognostic information in patients with gastric cancer.

Preoperative assessment in cases of adult megacolon suffering from moderate malnutrition.

Acquired megacolon is a chronic disease associated with constipation and malnutrition. Surgical treatment may be required for the alleviation of the intestinal symptoms, emphasizing the interest of nutritional assessment in this population. In a prospective study of 33 patients suffering from acquired megacolon and requiring either anterior resection or pull-through operation, standard anthropometric and biochemical measurements as well as the PNI of Buzby and Mullen were preoperatively assessed. Mean age of the population was 49 +/- 13 y, with 17 males and 16 females. The combined nutritional score indicated 63.6% of the population were malnourished (21/33) of the patients, whereas the Prognostic nutritional index (PNI) revealed 3 high-risk cases (9.1%), 9 with moderate risk (27.3%), and reduced risk for all others. Indeed, 39.4% (13/33) of the patients displayed surgical or septic problems. Chi-square analysis confirmed that both studied criteria were significantly associated with complications (p < 0.05), as morbidity was restricted predominantly to cases with unfavorable Prognostic nutritional index (PNI) results or clear signs of nutritional deficit. Both PNI and conventinoal nutritional assessment are valuable tools for the screening of these surgical candidates. Artificial alimentation was not used in this experience, but deserves consideration in selected patients. Nutritional status improved in the late postoperative period, with normalization of bowel function.

Refeeding procedures after 43 days of total fasting.

Refeeding syndrome encompasses fluid and electrolyte imbalances and metabolic, intestinal, and cardiorespiratory derangements associated with appreciable morbidity and mortality. Although refeeding syndrome has been well documented in concentration-camp subjects, and more recently during parenteral therapy of critically ill patients, little is known about the importance of refeeding syndrome during recovery from a hunger strike. Thus, we studied the response to a four-step dietary replenishment routine in eight hunger strikers who refused food for 43 d. In this retrospective, observational study, we assessed the safety and efficacy of the refeeding procedure and analyzed the clinical and nutritional course of the cohort during both starvation and refeeding, mainly on the basis of clinical as well as a few biochemical determinations. During starvation, average weight loss was about 18% and, with the exception of occasional oral vitamins and electrolytes, the subjects consumed only water. Available body-composition and biochemical profiles showed no clinically significant changes during starvation, but one-half of the group displayed spontaneous diarrhea at some time before refeeding. Stepwise nutritional replenishment lasted for 9 d, after which all patients tolerated a full, unrestricted diet. Only one episode of diarrhea occurred during this phase, and both clinical and biochemical indexes confirmed a favorable clinical course, without any manifestation of refeeding syndrome. In conclusion, we observed the following: 1) Hypophosphatemia and other micronutrient imbalances did not occur, nor was macronutrient intolerance detected. 2) Despite some episodes of diarrhea, nutritional replenishment was not associated with significant enteral dysfunction. 3) There was some fluid retention, but this was mild. 4) Acute-phase markers were abnormally elevated during the refeeding phase, without associated sepsis or inflammation.

Endoscopic treatment of benign postanastomotic annular stricture of the cervical esophagus.

Although most patients presenting with a fibrotic stricture at an esophagocolic or esophagogastric anastomosis respond well to the classical dilation therapy, a number of them do not and are therefore considered to have a condition refractory to the classical method. In these cases, we performed fiberesophagoscopic section and segmentation of the stenosing ring itself, which did not exceed one cm in length, using appropriate equipment such as an electric endoscopic scalpel. Widening of the strictured segment was completed with successive dilations using a Maloney type bougie. Dysphagia disappeared after the endoscopic procedure in 21 (84%) of the 25 patients with stricture of the cervical anastomosis, after esophagocoloplasty or esophagogastroplasty, without any serious complications.

[Critical analysis of the treatment of gastric ulcer by proximal gastric vagotomy]. / Análise crítica do tratamento da úlcera gástrica pela vagotomia gástrica proximal.

In the surgical treatment of gastric ulcer (G,U,), the same techniques have been employed as have been used in duodenal ulcer (D.U.). This correspondence also holds true with superselective vagotomy and proximal gastric vagotomy (P.G.V.). The technique was primarily indicated in the treatment of D.U. and had very exciting preliminary results, above all owing to its reduced morbidity both immediately and late after surgery, and to its almost null mortality. With a view to analyzing the results of the use of P.G.V. in the treatment of gastric ulcer, thirteen patients were operated upon who were bearers of G.U. not associated with D.U. nor prepyloric ulcer. There were no operating accidents or immediate post-operative complications, nor was there any mortality. In the post-operative period following lasting an average of 17.7 months, we observed the clinical manifestation of the ulcer and symptoms accompaning the operation in addition to performing endoscopy on all of the patients. Eight patients were absolutely asymptomatic after surgery; one had slight dysphagia that diminished about 3 months after P.G.V. Three patients had recurrence of the symptoms of ulcer and one complained of intense epigastric fullness, vomting, weight loss, and a crisis of diarrhea. Radiologic and endoscopic examinations showed that this last patient had hypotonia and marked gastric stasis that were corrected surgically by means of antrectomy and the reconstitution of GI tract by the BI technique, with good results. In three patients endoscopy showed postoperative recurrence of the G.U., one of whom is assymptomatic with the clinical treatment; the other two were submitted to antrectomy with BI anastomosis in one and a 2/3 gastrectomy with BI reconstruction in the other. The cure of the lesion in 23% of the cases in the post-operative follow-up lasting an average of 17.7 months permits us henceforward to contra-indicate the P.G.V. used per se for the treatment of G.U.

[Use of the Leveen shunt in the treatment of clinically intractable ascites]. / Uso da válvula de Le Veen no tratamento da ascite clinicamente intratável.

From January 1978 to August 1987, 21 patients received a peritoneovenous shunt using the Le Veen valve (LVV). The indications criteria were the long-term diuretic therapy failure (mean time = 24.4 months) or resistence to medical therapy during hospital internment. The 21 patients underwent 36 surgeries, being 4 valve position review and 11 changes of LVV. The mean age was 51.6 years. Fifteen patients had alcoholic cirrhosis, 3 postnecrotic cirrhosis, one Budd-Chiari syndrome, one mansoni Schistosomiasis, and one malignant ascites. Ten were Child B and 9 Child C patients. Eight patients with history of previous esophageal varices bleeding (EVB) underwent endoscopic sclerotherapy (EE) before LVV implantation. Seven patients died in the early postoperative period (3 Child B and 4 Child C patients). Three patients died due to EVB and the others as consequence of hepatic failure (one), cardiac insufficiency (one), sepsis (one), and bronchopneumonia (one). The mean follow-up was 19.9 months (1-61). Early LVV occlusion occurred in 4 patients and late valve occlusion in others 4 patients. The LVV changes were done at ambulatorial preceeding. Ten patients (47.6%) died in late follow-up and in these cases death was related to the main disease course. It is concluded that: 1) LVV is a useful therapy in patients with intractable ascites, since it is not the terminal manifestations of disease; 2) early mortality is related to liver function and late mortality to main disease course; 3) ascitic patients with EVB should undergo endoscopic sclerotherapy before LVV implantation.

Embolization to reverse severe recurrent hepatic encephalopathy.

Five patients with porto-systemic shunts, four spontaneous and one surgically created, presenting severe recurrent hepatic encephalopathy rebel to clinical treatment were angiographically examined. A spontaneous splenic-renal veins shunt was observed in four cases and a mesocaval shunt was identified in the remaining patient. Two thirds embolization of the spleen was able to control hepatic encephalopathy in two patients. Percutaneous transhepatic portography and selective embolization of the shunt was performed in two other patients with good results. Percutaneous transcaval embolization of the mesocaval shunt succeeded to control hepatic encephalopathy in the remaining patient. Splenic embolization is able to control hepatic encephalopathy in patients with splenomegaly and spontaneous porto-systemic shunt. Direct embolization of the shunt is also able to control hepatic encephalopathy as should be expected.

[Surgical treatment of portal hypertension in patients with liver cirrhosis]. / Tratamento cirúrgico da hipertensão portal em cirróticos.

Surgical options in the treatment of portal hypertension in cirrhotics are reviewed, regarding elective and emergency cases as well as the results in alcoholics and non-alcoholics. After literature review and personal experience analysis, it is concluded that endoscopic sclerotherapy should be the treatment of choice in cirrhotic patients with bleeding esophageal varices. When this fails, distal splenorenal shunt is indicated for compensated Child A and B. Regarding Child C and decompensated Child B, the choice should be a portocaval or meso caval shunts or esophageal transection with a stapler associated to splenectomy.

[Endoscopic resection of hamartoma of the duodenum]. / Ressecção endoscópica do hamartoma de duodeno.

Duodenal tumors are rare and, Brunner's glands proliferation encompass a small percent. The duodenal hamartoma generally has a polypoid configuration. It can present as two clinical conditions; bleeding and obstruction, even though most of the time it is asymptomatic or presents non specific gastrointestinal symptoms. Another possibility is the association with polypoid lesions of the large bowel, as it happens in Peutz Jeghers and Gardner's syndrome. Malignant transformation is exceedingly rare. Endoscopy has an important role, not only to ensure proper diagnosis, but also as a valuable therapeutic option.

[Doppler ultrasonography evaluation of paraumbilical vein and portal hypertension]. / Evaluation par échographie-Doppler de la veine para-ombilicale dans l'hypertension portale.

UNLABELLED: Portal hypertension is associated to the development of portosystemic collateral veins, particularly the paraumbilical vein. PURPOSE: To evaluate the biometric and hemodynamic characteristics of the portal vessels related to the presence of a patent paraumbilical vein, in the setting of portal hypertension secondary to hepatosplenic schistosomiasis. METHODS: 75 patients with portal hypertension secondary to hepatosplenic schistosomiasis were evaluated by Doppler US. The patients were studied based on the presence (group B) or not (Group A) of a patent paraumbilical vein. The diameter and blood flow velocity of the portal vessels and of the paraumbilical vein were recorded. RESULTS: The paraumbilical vein was detected in 17.33% of patients. The results showed an increase of the diameter of the main and left portal vessels whenever a patent paraumbilical vein was present (portal vein: A = 1.14 +/- 0.29 cm/B = 1.33 +/- 0.16 cm; left branch: A = 0.95 +/- 0.25 cm/B = 1.30 +/- 0.24 cm). The mean blood flow velocity was also increased in the portal trunk (A = 15.96 +/- 6.17 cm/sec/B = 19.82 +/- 6.26 cm/sec) and in the left portal branch (A = 14.77 +/- 4.29 cm/sec/B = 19.92 +/- 6.88 cm/sec). CONCLUSION: The presence of a patent paraumbilical vein is related to significant biometric and hemodynamic variations in the portal venous system, in the setting of portal hypertension secondary to hepatosplenic schistosomiasis.

[Intrahepatic and subcapsular hematoma of the liver after hepatic biopsy under laparoscopy. Contribution of ultrasonography]. / Hematoma intra-hepático e subcapsular do fígado após biopsia hepática sob visão laparoscópica. Contribuição ao seu estudo através da ultra-sonografia.

Over the last few years, ultrasound became important in characterization of space -occupying solid lesions of the liver. Recently, Canadian authors using this method, described a 23% incidence of intrahepatic or subcapsular hematoma after liver biopsy. We prospectively evaluated the incidence of this complication after liver biopsy under laparoscopic guidance in 8 cirrhotic patients, 7 with steatosis, 7 chronic active hepatitis and 4 with intrahepatic cholestasis. Biopsy was performed under general anesthesia provided that prothrombin activity was over 50%, serum fibrinogen was over 100% and platelets over 50.000/mm3. In none of 26 consecutive patients, was an intrahepatic or subcapsular hematoma observed.

[Hepatocyte necrosis and intrahepatic cholestasis in the postoperative period of patients undergoing heart surgery with the use of extracorporeal circulation: significance of clinical, epidemiologic, surgical and laboratory parameters in evaluating prognosis]. / Necrose hepatocitária e colestase intrahepática no pós-operatório de pacientes submetidos à cirurgia cardíaca com o emprego de circulação extracorpórea: importância dos parâmetros clínicos, epidemiológicos, operatórios e laboratoriais na avaliação do prognóstico.

Sixteen patients with jaundice after heart surgery with extracorporeal circulation, were studied. They were divided in 2 groups, according to the postoperative outcome; either death (group I) or hospital discharge (group II). Clinical, epidemiological, surgical and laboratorial aspects were compared in order to ascertain their role in the outcome. The results were analysed by the Student-t test. The main cause of death was low output syndrome, which occurred in 10 cases (62.5%), 5 of them died (31%). A statistically significant difference was observed in the postoperative values of serum GOT (p less than 0.01), GPT (p less than 0.01) and total bilirubin (p less than 0.01), which were then considered prognostic indicators in these patients.