Spontaneous resolution of intrarenal pseudoaneurysm.

A case of intrarenal pseudoaneurysm after blunt trauma in a 12-year-old girl is reported. Clinical evolution was characterised by gross hematuria and colic pain bouts, and several pseudoaneurysms were confirmed through computerised tomography and Doppler ultrasound. In spite of strict bedrest, hematuric episodes occurred on day 11 and day 21 after admission. The pseudoaneurysms were confirmed by Doppler ultrasound and conservative treatment was rejected. 48 hours later, a therapeutic arteriography was performed, but no pseudoaneurysm could be identified, only an arteriovenous fistula that was embolised with coils. To our knowledge this is the first case of documented spontaneous resolution of intrarenal pseudoaneurysm. This case raises the possibility of continuing conservative treatment even in the presence of an intrarenal pseudoaneurysm.

Postinfarction ventricular septal defect. An efficacious technique for early surgical repair.

Between December 1982 and June 1987, seven consecutive patients (52 to 77 years old) underwent early surgical repair of postinfarction ventricular septal defect. The defect was diagnosed 3 to 10 days after the myocardial infarction. A new repair technique was used which stresses that no part of the infarcted septum be resected. This technique consists of a transinfarction incision in the left ventricle, placement of a fine Dacron fabric patch that covers all the infarcted septum and closes the ventricular septal defect, and placement of a second Dacron fabric patch that reinforces the infarcted anterior wall of the heart and supports the buttressed double suture closure of the left ventriculotomy. One very ill patient of this series died during the operation (mortality rate 14.3%). Three patients required the help of intraaortic balloon counterpulsation postoperatively, and five needed inotropic drug support. None of the patients had excessive bleeding. Two initial patients had a small left-to-right interventricular shunt. Postoperative angiographic studies and Doppler echocardiography confirmed the existence of a nonsignificant residual ventricular septal defect in these two patients and showed good geometry of the left ventricle with no aneurysm formation in all six survivors. This technique seems to be efficacious. It can be expeditiously performed, and the risks of postoperative complications related to the technique appear to be minimal.

Heart and unilateral lung transplantation for cardiomyopathy with high pulmonary vascular resistance.

Heart and left lung (en bloc) transplantation was used as an approach to end-stage cardiomyopathy with very high pulmonary vascular resistance. This surgical method was applied to a 13-year-old girl who did very well initially, but died 5 months later of severe pulmonary and cardiac rejection. The pulmonary perfusion scintigraphy showed equalization of the blood flow in both lungs after 42 days, and complete reversal of the pulmonary vascular changes in the opposite lung was observed at autopsy.

Helical CT evaluation in the preoperative staging of gastric adenocarcinoma.

INTRODUCTION: The aim of this study is to evaluate helical CT as a basic preoperative test for the staging of gastric adenocarcinoma. MATERIAL AND METHOD: We enrolled 50 patients with a diagnosis of gastric adenocarcinoma, evaluated helical CT scans, and compared their findings to the microscopic, pathology-confirmed ones obtained by laparotomy. UICC's TNM classification, 5th edition (May 1997), was used. RESULTS: Best results regarding Sensitivity were obtained in the diagnosis of lymph node disease (83%; 69-92%); regarding specificity we obtained 92% (79-98%) for T4, and 89% (77-96%) in metastasis detection. Accuracy was 70% for T1-T2, and 62% for T3. CONCLUSIONS: 1. For the T category, helical CT effectively detects advanced cases classified as non-resectable. 2. For the N category, helical CT prediction is better than ever before with previous CT generations. 3. For the M category, helical CT is a useful test to identify the presence of liver metastases that would render surgery unnecessary.

[The heart-lung transplant. Initial clinical experience]. / Transplante cardiopulmonar. Experiência clínica inicial.

PURPOSE: To assess this initial clinical experience with heart-lung transplantation in Brazil. METHODS: Four patients underwent heart-lung transplantation from December 1988 to March 1990, one patient with cardiomyopathy and high pulmonary resistance, two patients with primary pulmonary hypertension and another with pulmonary silicosis. The heart lung blocks were harvested from the donor using cardiopulmonary bypass and deep hypothermia. They were transplanted to the recipient by anastomosing the trachea, right atrium or venae cavae, and the ascending aorta. RESULTS: The second patient died on the 5th postoperative day due to respiratory insufficiency with consequent brain lesions. The first and third patients had survived nine months and 42 days respectively. The 4th patients is asymptomatic eight months after the operation. The main complications were bleeding in two patients, acute pulmonary rejection in three of them and obliterans bronchiolitis in one patients. CONCLUSION: The heart lung transplantation is a challenging procedure which results are progressively improving with the development of better surgical technique and clinical concepts.

[Surgical management of anterior communicating artery aneurysms based on computed tomographic angiography with three-dimensional reconstruction and without preoperative angiography]. / Tratamiento quirúrgico de los aneurismas de la arteria comunicante anterior basado en el estudio de angio-TAC eon reconstrucción tridimensional y sin angiografía preoperatoria.

OBJECTIVE: To demonstrate the usefulness of threedimensional computed tomographic angiography (CT- 3D-angiography) in the microsurgical management of aneurysms of the anterior communicating artery (AComA). MATERIALS AND METHODS: A total of 28 consecutive patients with ruptured aneurysms of the AComA diagnosed by means of CT-3D-angiography and without preoperative angiography were operated on. The findings of the CT-3D-angiography, microsurgical exploration and clínical data were evaluated. RESULTS: There were no false positive findings nor false negative findings in the diagnosis of the AComA aneurysms. The global sensibility of the examination was 87.9%. The CT-3D-angiography study shows a left A1 segment dominance in 53.6% of cases, a right A1 dominance in 14.3% of cases and both A1 segments of the same diameter in 32.1%. Aneurysms growing on the traject of the AComA were associated with both A1 segments of the similar diameter and an AComA traject pararell to the transverse plane. Aneurysms implanted on the A1-A2 junction were associated with a dominant homolateral A1 segment and an oblique AComA traject. Microsurgical management of the lesions was done a mean of 3.7 days after bleeding. CONCLUSION: The study of patients with acute subarachnoid hemorrhage with CT-3D-angiography allows a reliable diagnosis of AComA aneurysms. The examination gives some anatomical data that allow the study of the hemodinamic changes involved in the development of the aneurysms. Moreover, provides usefull information for the microsurgical clipping. CT-3D-angiography allows to improve some health indicators but its impact in the final result of the patients needs more clinical data.

[Surgical management of posterior communicating artery aneurysms based on computed tomographic angiography with three-dimensional reconstruction and without preoperative angiography]. / Tratamiento quirúrgico de los aneurismas de la arteria comunicante posterior basado en el estudio de angio-tac con reconstrucción tridimensional y sin angiografía preoperatoria.

OBJECTIVE: To demonstrate the usefulness of three-dimensional computed tomographic angiography (CT-3D-angiography) in the microsurgical management of aneurysms of the posterior communicating artery (PComA). MATERIALS AND METHODS: A series of 27 patients with aneurysms of the PComA diagnosed by means of CT-3D-angiography and without preoperative angiography (group A) were compared with a series of 34 cases diagnosed by cerebral angiography. The findings of the CT-3D-angiography, angiography, microsurgical exploration and clinical data were evaluated. RESULTS: A total of 75 aneurysms were diagnosed preoperatively in 66 patients and 3 additional lesions were found postoperatively in group A. The sensitivity of the CT-3D-angiography was 91.7% for diagnosis of any aneurysm with an specifity of 100%, being the snsibility of angiography a 100% and its specifity 94.9%. Mortality rate was 4.5% without differences between groups regarding clinical results or complications. Both the preoperative timing and hospitalization time were shorter in group A. CONCLUSION: The study of patients with acute subarachnoid hemorrhage with CT-3D-angiography allows a reliable diagnosis of PComA aneurysms. Moreover, provides usefull information for the microsurgical clipping. When compared with angiography in the diagnosis of PComA aneurysms, CT-3D-angiography allows to improve some health indicators with similar clinical results and complications.

[High-resolution electrocardiogram in the study of early rejection of heart transplant by spectral temporal mapping]. / Eletrocardiograma de alta resolução no estudo da rejeição precoce do transplante cardíaco pelo mapeamento espectro-temporal.

At the present time there is great interest in seeking non invasive methods for reduction and precise orientation of the endomyocardial biopsy after heart transplant. Two cases of orthotopic heart transplant followed by spectro temporal mapping of signal averaging electrocardiography and integral calculation are reported. The results that identified the rejection process are presented and several aspects of this method are discussed.

[Myxoma of the right atrium]. / Mixoma de átrio direito.

The authors report the case of a 31 year-old male with right atrial myxoma whose clinical manifestations included: malaise, dizziness and dyspnea on great exertion. At physical examination, a tricuspid systolic and diastolic murmur of mean intensity was found. The chest radiography and the electrocardiogram signs were of right atrial and ventricular enlargement, and the diagnosis was made with the B-mode echocardiogram. The patient underwent surgical removal of the tumoral mass and diagnostic confirmation was made with the histopathologic study of the 75 x 50 x 40 mm piece. The patient obtained clinical, electrocardiographic and radiologic remission.

[Heart-lung transplantation. Initial clinical experience]. / Transplante cardiopulmonar. Experiência clínica inicial.

PURPOSE: To assess this initial clinical experience with heart-lung transplantation in Brazil. METHODS: Four patients underwent heart-lung transplantation from December 1988 to March 1990, one patient with cardiomyopathy and high pulmonary resistance, two patients with primary pulmonary hypertension and another with pulmonary silicosis. The heart lung blocks were harvested from the donor using cardiopulmonary bypass and deep hypothermia. They were transplanted to the recipient by anastomosing the tracheae, right atrium or venae cavae, and the ascending aorta. RESULTS: The second patient died on the 5th postoperative day due to respiratory insufficiency with consequent brain lesions. The first and third patients had survived nine months and 42 days respectively. The 4th patients is asymptomatic eight months after the operation. The main complications were bleeding in two patients, acute pulmonary rejection in three of them and obliterans bronchiolitis in one patients. CONCLUSION: The heart lung transplantation is a challenging procedure which results are progressively improving with the development of better surgical technique and clinical concepts.

[Heterotopic heart transplantation. Initial clinical experience]. / Transplante cardíaco heterotópico. Experiência clínica inicial.

PURPOSE: To report our initial clinical experience with heterotopic heart transplantation, stressing its indications and a new modification in surgical technique. METHODS: We studied three patients underwent heterotopic heart transplantation, using an original technique in one of them. This new technique allows to connect both pulmonary arteries without any prosthetic tube. RESULTS: One early death and two late survivors, with 17 and 20 months of follow-up. One of them is clinically well and practices sports, regularly. CONCLUSION: Heterotopic heart transplantation could be considered as a good therapeutic option for end-stage patients with cardiomyopathy and right pulmonary vascular resistance, specially those with right ventricle. It can improve general results of heart transplantation because it reduces the early risks related to hemodynamic problems in a selected group of patients.

Melanoma maligno gastrointestinal en paciente albino: a propósito de un caso / Gastrointestinal melanoma in an albino patient: Report of a case

Los albinos tienen predisposición al padecimiento de determinados tipos de cáncer cutáneo, pero el melanoma no es común. Entre los pocos artículos que documentan su aparición en estos pacientes, la afección gastrointestinal por melanoma aparece con relativa frecuencia, ya sea en forma de tumor primario o metástasis. Se presenta el caso de una paciente mujer de 70 años con una lesión gástrica y otra intestinal, detectadas mediante tomografía computada. El estudio anatomopatológico fue compatible con el diagnóstico de melanoma amelanótico. Pese a su escasa incidencia en albinos, el melanoma es una opción que no puede descartarse. Es importante, además, revisar los diferentes componentes del tracto gastrointestinal ante la existencia (o no) de un melanoma primario conocido...

Heart transplantation in Chagas' disease. 10 years after the initial experience.

BACKGROUND: Heart transplantation (HT) as a therapeutic option for end-stage chronic Chagas' heart disease (CCHD) is controversial. Reactivation of Trypanosoma cruzi infection and recurrence of the disease in the allograft are likely to occur. Furthermore, active myocarditis has been reported to predispose patients to an increased incidence and severity of rejection. METHODS AND RESULTS: We prospectively investigated the long-term follow-up of 10 patients with CCHD who underwent HT. Immunosuppression was based on cyclosporine A and azathioprine. T cruzi reactivation was prevented with benzonidazole. Besides allograft rejection surveillance, T cruzi infection was monitored through blood tests, myocardial biopsies, and serological tests. Over a mean follow-up period of 34 +/- 38 months (range, 73 to 124 months), 7 patients are alive and in NYHA functional class I. Life expectancy was 78% for the second year and 65% for 10 years. Rejection was less frequent in chagasic than in age- and sex-matched control patients (mean +/- SD, 1.60 +/- 1.26 versus 5.70 +/- 1.89 episodes per patient, respectively; P = .0001); decreased severity of rejection was also observed (P = .006). T cruzi parasitemias detected on three occasions were successfully treated with benzonidazole. There were no signs of recurrence of the disease in the allograft. CONCLUSIONS: These results suggest an important role of HT in the treatment of CCHD. There was a low frequency of T cruzi infection reactivation and no signs of recurrence of the disease in the allograft. The surprisingly decreased rejection incidence and severity require further studies for elucidation.