Immunohistochemical expression of heparanase isoforms and syndecan-1 proteins in colorectal adenomas.

The proteoglycan syndecan-1 and the endoglucuronidases heparanase-1 and heparanase-2 are involved in molecular pathways that deregulate cell adhesion during carcinogenesis. Few studies have examined the expression of syndecan-1, heparanase-1 and mainly heparanase-2 proteins in non-neoplastic and neoplastic human colorectal adenoma tissues. The aim of this study was to analyze the correlation among the heparanase isoforms and the syndecan-1 proteins through immunohistochemical expression in the tissue of colorectal adenomas. Primary anti-human polyclonal anti-HPSE and anti-HPSE2 antibodies and primary anti-human monoclonal anti-SDC1 antibody were used in the immunohistochemical study. The expressions of heparanase-1 and heparanase-2 proteins were determined in tissue samples from 65 colorectal adenomas; the expression of syndecan-1 protein was obtained from 39 (60%) patients. The histological type of adenoma was tubular in 44 (67.7%) patients and tubular-villous in 21 (32.3%); there were no villous adenomas. The polyps were <1.0 cm in size in 54 (83.1%) patients and ≥1.0 cm in 11 (16.9%). The images were quantified by digital counter with a computer program for this purpose. The expression index represented the relationship between the intensity expression and the percentage of positively stained cells. The results showed that the average of heparanase-1, heparanase-2 and syndecan-1 expression index was 73.29 o.u./µm², 93.34 o.u./µm², and 55.29 o.u./µm², respectively. The correlation between the heparanase-1 and syndecan-1 expression index was positive (R=0.034) and significant (P=0.035). There was a negative (R= -0.384) and significant (P=0.016) correlation between the expression index of heparanase-1 and heparanase-2. A negative (R= -0.421) and significant (P=0.008) correlation between the expression index of heparanase-2 and syndecan-1 was found. We concluded that in colorectal adenomas, the heparanase-1 does not participate in syndecan-1 degradation; the heparanase-2 does not stimulate syndecan-1 degradation by the action of heparanase-1, and the heparanase-2 may be involved in the modulation of the heparanase-1 activity.

Purpose in life and outcome of treatment for alcohol dependence.

A number of studies have linked the development of substance abuse problems to a lack of purpose or meaning in life, and a few studies have demonstrated an increase in sense of life purpose through substance abuse treatment programmes. The present study extended past research by examining the relationship of purpose in life to treatment outcome assessed three months after completion of treatment. The subject sample comprised 131 people in in-patient treatment programmes or awaiting treatment for alcoholism (in some cases in addition to other drug addictions). Consistent with previous research, the mean Purpose in Life Test (PIL) score before treatment was significantly below the normal range and the mean PIL score at the end of in-patient treatment was within the normal range. Furthermore, the PIL score at the end of treatment was predictive of changes in intimate relationships and health at follow-up. It was also predictive of follow-up drinking/drug use status. However, the pattern of prediction differed in the two treatment groups. Post-treatment PIL score was a positive predictor of improvement in a skill-based treatment centre, and a negative predictor in a more authoritarian, confrontation-based programme. The distinction between internally and externally derived senses of meaning is presented as one possible explanation of these findings.

Jejunal perforation caused by abdominal angiostrongyliasis.

The authors describe a case of abdominal angiostrongyliasis in an adult patient presenting acute abdominal pain caused by jejunal perforation. The case was unusual, as this affliction habitually involves the terminal ileum, appendix, cecum or ascending colon. The disease is caused by the nematode Angiostrongylus costaricensis, whose definitive hosts are forest rodents while snails and slugs are its intermediate hosts. Infection in humans is accidental and occurs via the ingestion of snail or slug mucoid secretions found on vegetables, or by direct contact with the mucus. Abdominal angiostrongyliasis is clinically characterized by prolonged fever, anorexia, abdominal pain in the right-lower quadrant, and peripheral blood eosinophilia. Although usually of a benign nature, its course may evolve to more complicated forms such as intestinal obstruction or perforation likely to require a surgical approach. Currently, no efficient medication for the treatment of abdominal angiostrongyliasis is known to be available. In this study, the authors provide a review on the subject, considering its etiopathogeny, clinical picture, diagnosis and treatment.

Spontaneous perforations of the small intestine.

BACKGROUND AND METHODS: The present study describes the procedures used by the authors in the management of 34 patients with spontaneous perforation of the small intestine. RESULTS: Only one (2.9%) of the patients had the perforation cause diagnosed before laparotomy; 27 (80%) cases showed ileal perforative lesions while seven (20%) had jejunal lesions; 31 (91.1%) patients presented single perforations and three (8.8%) had multiple ones. Intestinal resection followed by anastomosis or ileostomy and colostomy, was carried out in 21 (61.7%) cases, and 13 (38.2%) patients were submitted to exeresis with edge restoration and lesion suture. The cause of perforation could be identified in 29 (86.3%) cases while in five (14.7%) patients the cause was considered idiopathic. Eighteen (53%) patients recovered from surgery and were discharged; there were 16 (47%) deaths resulting from a number of complications. CONCLUSIONS: Since the prognosis regarding this disease depends on the peritoneal infection severity level, the patient's organic resistance, and most of all, the time interval spent until the treatment is initiated, the authors emphasize the need to have a laparotomy performed as early as possible considering that this procedure provides the best chances of survival and health recovery.

The role of surgery in the treatment of primary gastric lymphoma.

The present retrospective study of 23 patients with primary gastric lymphoma had the objective of determining the role of surgical treatment on survival. All patients were submitted to gastric resection with regional lymph node removal. Nine patients (39.1%) received supplementary treatment (chemotherapy and/or radiotherapy). According to the Kiel classification, the most frequent histological type was the centroblastic (29.1%), and most patients (60.9%) had a low-grade lymphoma. According to the Ann Arbor classification, modified by Musshoff and Schmidt-Vollmer, stages were IE in 52.1%, II1E in 8.7%, II2E in 13.1%, and IV in 26.1% of the cases. Mean survival was 29.3 months. The variables that influenced survival rates were age, advanced stage tumor, and receiving postoperative adjuvant therapy. Analysis of our cases suggests that complete lesion resection along with adjacent lymph nodes, and supplementary postoperative treatment is the best approach for a resectable primary gastric lymphoma.

Surgical treatment for colorectal endometriosis.

The authors studied the surgical treatment of patients with intestinal endometriosis. A total of 10 patients, with a median age range of 43 years, underwent an operation. Cramp abdominal pain (100%), diarrhea (30%), constipation and enterorrhagia (20%) dominated the clinical picture. At the time of surgery, four patients presented intestinal obstructive symptoms. Five (50%) patients reported gynecological complaints. Four patients were infertile and five had prior surgical gynaecological events. Seven cases presented sigmoid involvement, and three had involvement of the cecal appendix. Pre-operative diagnosis was carried out in two patients only. Surgical indications were due to suspicion of cancer (4 patients), appendicitis (3 patients), diverticular disease (1 patient) and unmanageable pain (2 patients). The following procedures were performed: left colectomy (2 cases), rectosigmoidectomy (3 cases), sigmoidectomy (3 cases), colostomy (2 cases) and three appendicectomy cases associated with concomitant gynecological interventions. No postoperative complications or deaths were observed. The authors emphasize that intestinal stenotic lesions should be treated by means of extirpation while the parietal nodule should be treated by exeresis. Intestinal endometriosis should be suspected in cases of lower abdomen recurrent pain in premenopausal infertile women or with previous surgical, gynecological events associated with intestinal symptoms or distal colon stenosis.

Primary non-Hodgkin lymphoma of the right colon: a retrospective clinical-pathological study.

The objective of this study was to analyze the results of surgical treatment of primary non-Hodgkin lymphomas of the right colon. Ten patients were operated on with curative intention. Dawson's criteria were used to characterize the colonic lymphoma as a primary lymphomas. In the staging of the tumor, the Ann Arbor classification for gastrointestinal lymphomas modified by Musshoff and Schmidt-Vollmer was used. The histological classification was made by using the International Working Formulation Group system. All patients were submitted to radical right colectomy and 6 of them received postoperative chemotherapy. The overall average survival was 39.2 months. Four of the patients are still alive, without active disease, with an average survival of 85.2 months. Six patients died due to relapse in the abdomen, with an average survival of 8.2 months. These results suggest that it is advantageous to patient survival to have them submitted for resection of their lesions at an initial stage of the disease (IE and IIE1). Chemotherapy must be used as a complementary treatment in locally advanced lesions, in an attempt to control the residual microscopic disease.

[Treatment of cicatricial stenosis of the proximal common hepatic duct. Study of 11 cases]. / Tratamento das estenoses cicatriciais da porção proximal do ducto hepático comum. Estudo de 11 casos.

Eleven patients with cicatricial stenosis in the junction area of hepatic ducts were evaluated. In all patients the injury occurred during cholescystectomy and no operative cholangiography was performed. In 3 patients the injury was recognized during the initial cholecistectomy. Ten patients had been operated on at least one time to correct the injury in other Services. Four cases had duct or peritoneal drainage. There was an attempt of reanastomosis in two cases. Five patients had a bilio-digestive anastomosis performed in variable occasions. Two patients were reoperated 5 times, one patient 3 times. The others were submitted to one or 2 reoperations. There were a period of 1 to 72 months between the injury and last reoperation. Jaundice was the most common presenting manifestation since it appeared in all patient except one. Five patients had biliary cirrhosis. Roux-en-Y hepaticojejunostomy was carried out in all cases after enlarging the biliar stoma by longitudinal section on the left hepatic duct and performing a termino-terminal anastomosis. The 10 or 12 caliber Kehr drain used was taken out after the control cholangiography, carried around the second postoperative week. Concerning the long term results, one patient died of recurrent cholangitis six months after the 6th reoperation and one patient 14 months after the 4th reoperation of liver failure. Both had biliary cirrhosis. Two patients, remained assymptomatic for 60 months and 3 patients for 24, 37 and 56 months. The importance of preventing this severe complication is stressed by the authors. Patients with such lesions need be referred to specialized centers where well trained surgeons are available. The technique herein presented seems us to be a good option.

[Acute emphysematous cholecystitis. Report of a case and review of the literature]. / Colecistite aguda enfisematosa. Relato de um caso e revisão da literatura.

The authors report a case of acute emphysematous cholecystitis (AEC) operated on at the University Hospital of ABC Medical School (São Paulo), with a review of the literature. The infrequency of this finding and the participation of local ischemic factors, associated with secondary infection by gas forming bacteria are pointed out. The authors emphasize the importance of considering this entity potentially more severe than acute non-emphysematous cholecystitis (AnEC) because in AEC gallbladder gangrene is 30 times higher and perforation occurs 5 times more frequently than in AnEC. Besides, the patient with AEC may shows no clinical signs of severity, as in the case reported, where gallbladder gangrene was seen at surgery. In AEC, diagnosis is established usually when the plain abdominal X-ray shows gas within the gallbladder or in its walls. The best results are obtained with cholecystectomy and antibiotic therapy.

[Retroperitoneal cystic lymphangioma]. / Linfangioma cístico retroperitonial.

The lymphangioma is a rare disease, more frequently reported in children and just occasionally in the adult patient. The lymphangioma is considered a benign neoplasm of embryonic origin of the lymphatic vessels. Its habitual location is in the cervical and axillary area; it is rarely found in the abdominal cavity and exceptionally in the retroperitonio. In this latter location, the lesion habitually is asymptomatic. The clinical diagnosis of the retroperitoneal cystic lymphangioma is not often due to its rarity and the absence of clinical expression. The size of the lesion is more important than its location to the symptomatology development. The findings of the abdominal ultrasonography and computerized tomography of the abdomen usually show a cystic lesion and its location. The treatment is surgical and it consists of the resection of the cyst or group of cysts once the liquid accumulation in its interior may be responsible for the development of some important complications of this disease. The cure is obtained when the lesion is completely resected also with the resection of eventual adhesive structures. The relapse may take place when the resection is incomplete. A case of retroperitoneal lymphangioma in a female adult patient as incidental finding of abdominal ultra-sonography is described. It is discussed the clinical picture, the radiologic diagnosis, the treatment and the prognostic of this unusual disease.

[Gastric epithelioid leiomyoma (leiomyoblastoma). Analysis of a case and review of the literature]. / Leiomioma epitelióide gástrico (leiomioblastoma). Análise de um caso e revisão da literatura.

The authors report a case of gastric epithelial leiomyoma (leiomyoblastoma). Macroscopically, such tumors resemble leiomyoma, with a biological behavior between leiomyoma and leiomyosarcoma. A review of the medical literature indicates that gastrointestinal bleeding is the most usual manifestation. Gastrointestinal seriography and endoscopy are the most utilized diagnostic exams. The endoscopic biopsy, many times, is unable to confirm the malignant or benign nature of the tumor. It is emphasized the importance of identifying the potentially malignant tendency of the tumor, indicated, mainly, by histology and mitotic counting. The treatment is surgical and consists of local or gastric resection, according to the neoplastic localization, its extension, infiltration, biological nature and the presence of multiple tumors. In the case reported, the patient was operated in urgency because of hemoperitoneum and the source of bleeding was a neoplastic vessel in the anterior wall of the antrum, which was not resected at that time. Later on, a biopsy of the gastric tumor performed during a routine surgery disclosed the real nature of the disease. Once the histopathological diagnostic was made and its potential malignant evolution detected the patient was re-operated. A partial gastrectomy with removal of the antrum was performed. Now, the patient has been asymptomatic with no evidences of metastasis after 30 months of the diagnostic.

[Surgical procedures in selected proctological patients with local anesthesia. Study of 150 cases]. / Procedimentos cirúrgicos em pa cientes proctológicos selecionados, sob anestesia local. Estudo de 150 casos.

Experience in the treatment of 150 patients with anorectal disorders and disorders of the sacrococcygeal region who were operated on with local anesthesia at the University Hospital, ABC Medical School, São Bernardo do Campo, SP, Brazil, from March 1995 to March 1998. The anesthesia technique, the operations carried out and the tolerance to the procedure are reported. Intraoperative morbidity was 10.6% (16 patients), and postoperative morbidity was 6% (nine patients). The age of patients was between 15 and 92 years old, with mean age 42 years old; 58% of patients were male and 42% female. Surgical mean time was 45 minutes and the patients remained in the hospital for a mean time of 8 hours. All of patients was instructed about the anesthesia technique, their advantages and disadvantages, and only with their permit the surgery was programmed. Hospitalization was required in five patients (3.3%). The anesthesia technique employed was the same for all patients. Upon survey, 96.7% of the patients stated they did not feel pain during the surgery and that they would go through the procedure again. The authors conclude the surgical treatment of anorectal disorders and disorders of the sacrococcygeal region with local anesthesia is viable and safe, and in addition, is well accepted by the patients.

Gastric necrosis and perforation as a complication of splenectomy. Case report and related references.

Necrosis of the stomach after isolated splenectomy with the formation of gastrocutaneous fistula is a rare event that occurs in less than 1% of splenectomies. It is more frequent when the removal of the spleen is done because of hematological diseases. Its mortality index can reach 60% and its pathogenesis is controversial, as it may be attributed both to direct trauma of the gastric wall and to ischemic phenomena. Although the stomach may exhibit exuberant arterial blood irrigation, anatomical variations can cause a predisposition towards the appearance of potentially ischemic areas, especially after ligation of the short gastric vessels around the major curvature of the stomach. Once this is diagnosed in the immediate postoperative period, it becomes imperative to reoperate. The surgical procedure will depend on the conditions of the peritoneal cavity and patient's clinic status. The objective of this study was to report on the case of a patient submitted to splenectomy because of closed abdominal traumatism, who then presented peritonitis and percutaneous gastric fistula in the post-operative period. During the second operation, perforations were identified in anterior gastric wall where there had been signs of vascular stress. The lesion was sutured after revival of its borders, and the patient had good evolution. Prompt diagnosis and immediate treatment of this unusual complication are needed to reduce its high mortality rate.

[Multiple retroperitoneal neurofibroma. Report of a case]. / Neurofibroma múltiplo retroperitoneal. Relato de um caso.

Tumors of nervous origin in the retroperitoneum are rare without specific symptoms which diagnosis is usually very difficult. The authors report a case of an asymptomatic patient with two benign retroperitoneal neurofibromas, one of them calcified and located near the inferior pole of the left kidney; the other tumor was closely adhered to the pancreatic tail in the supramesocolic region. Both were resected with appropriated surgical margins. The histopathologic and immunohistochemical studies established the correct diagnosis of the lesions. The authors comment the diagnostic tests of these tumors, their possible malignant degeneration and their surgical treatment.

[Carcinoid tumors of the gastrointestinal tract. Analysis of 21 cases]. / Tumores carcinóides do trato gastrointestinal. Análise de 21 casos.

Twenty-one patients with carcinoid tumors have been analysed. Out of 18 patients the diagnostic was made at operation and out of 3 by autopsy. The most frequent sites of the primary tumors were the appendix (38.1%), ileum (23.8%) and colon (19.9%). Asymptomatic tumors were found incidentally in 10 patients (55.5%). The symptomatic neoplasms were more common in the ileum. No one patients in this series obtained the diagnostic of carcinoid tumors before operation or autopsy. It was not observed the malignant carcinoid syndrome. Sixteen patients (88.8%) were submitted to resection and the mean survival was 10.7 years. Two patients (11.1%) were submitted to palliative operations and the mean survival was 3.5 months. The incidence of metastases in cases with carcinoid greater than 2.0 cm in diameter was 71.4%; on the other hand, the patients with carcinoids 2.0 cm in diameter or smaller than this size disclosed metastases in 7.6%. No patients with appendix carcinoid showed metastases and all patients with metastases presented ileum or colon carcinoids. In this series, the prognostic was related with the lesion's size, the localization of the tumor in the gastrointestinal tract and with the resection or not of the primary neoplasm.

Detection of Helicobacter pylori in gastric cancer.

BACKGROUND AND OBJECTIVES: Considering the high prevalence of stomach cancer in the northern region of Brazil and the recognized relationship between chronic gastric inflammation caused by Helicobacter pylori, and its carcinogenic potential, the objective we had with this study was to investigate the presence of the microorganism in macro and microscopic presentations of neoplasm in different regions of the stomach, and in non-malignant lesions concomitant to the adenocarcinoma in patients originating from the metropolitan area of Belém (State of Pará, Brazil). METHODS: Examinations were made on 172 patients divided into two groups: group I, formed by 75 patients with gastric carcinoma, and group II, formed by 97 patients with mild enanthematic gastritis, considered control group. The diagnosis was obtained during endoscopic examination and the respective biopsy. Gastric neoplasms were classified macroscopically in accordance with Borrmann's classification, and microscopically in accordance with Laurén's classification. In group I, 54 patients were male and 21 female while in group II, 22 patients were male and 75 female. The average age in group I was 61.2 years (range 27 to 86 years), while in group II it was 37.5 years (range 16 to 69 years). Thin sections were prepared and stained using the hematoxylin-eosin method. In the Helicobacter pylori research, the modified Gram stain was utilized. Statistical analysis was done by utilizing the chi-squared (chi 2) test, Mann-Whitney test (U), and Fisher's exact test. RESULTS: The results showed the detection of Helicobacter pylori were significantly greater in patients with mild enanthematic gastritis than in patients with gastric carcinoma. The presence of Helicobacter pylori in patients with gastric carcinoma and mild enanthematic gastritis was significantly greater in the antral region than in other gastric regions. Helicobacter pylori detection in patients with gastric carcinoma did not present a significant difference in relation to the macroscopic aspect of the tumor either intestinal or diffuse histological types. CONCLUSIONS: These data suggest the presence of the bacteria is predominant in the antral region and it does not show relation with the macroscopic types or histological intestinal or diffuse types of gastric carcinoma.

[Isolated metastasis of squamous cell carcinoma of the esophagus in the terminal ileum. Report of a case]. / Metástase isolada de carcinoma espino-celular do esôfago no íleo terminal. Relato de um caso.

Squamous cell carcinoma of the esophagus, with isolated metastasis to the terminal ileum, is a rare finding. Only 18 of such cases have been reported in the medical literature, all of them found at necropsies. The accurate examination of the abdominal cavity, after performing a gastrostomy, showed a neoplastic lesion in the terminal ileum, which was then resected. The histopathological examination revealed the metastatic nature of the lesion. The authors emphasize the importance of a complete and accurate revision of the abdominal cavity on patients with esophagus squamous cell carcinoma.

[Adenocarcinoma of the cecal appendix. Report of a case of the colic type]. / Adenocarcinoma do apêndice cecal. Relato de um caso do tipo cólico.

Regarding the event of an adenocarcinoma of the colic type of the cecal appendix, operated on at the ABC Medical College Hospital, the authors summarize the subject stating that, among the appendiceal carcinoma, this particular one tends to spread, by the veins or lymphatics, besides spreading by contiguity. This carcinoma hardly presents a symptomology of its own. It appears fairly often as acute appendicitis. The authors also state the difficulty for a macroscopic diagnosis. Thus, its real nature is determined, in general, only after the histologic exam of the removed part. The right hemicolectomy is the most indicated surgery and best results are obtained in the first surgery or 30 days afterwards. About the reported case the patient was operated on with the pre and intra operatory diagnosis of appendicitis and the histologic exam, on top of confirming it, pointed out the presence of neoplasm. After the indication for reoperation, the prompt spreading of the neoplastic disease offered no means to perform any other surgery disclosing its malignant potential.

[Colorectal lipomas: anatomoclinical study of 29 cases]. / Lipomas colorretais: correlação anatomoclínica de 29 casos.

OBJECT: To evaluate the incidence of colorectal lipomas, its diagnostic methodology and therapeutic management. CASUISTIC AND METHODS: The reviewed necropsies performed in a six years period and the patients' records from colorectal lipomas cases treated up to 1965 until 1993 were studied enhancing the clinical presentation, their diagnosis and therapy. The 29 cases of submucosal intestinal lipomas were disposed in three groups. The first group with ten patients lipomas were detected at necropsies. The second group with 11 symptomatic patients and group three with 8 asymptomatic patients which lipomas were discovered accidentally in surgical specimens resected due to neoplasm or in the course of diagnostical procedure. RESULTS: 0.56% of patients who were submitted to necropsy disclosed colorectal lipomas situated preferentially in right colon and in female. Enterourhage was the most often symptom (54.5%) in the group two, followed by cramp abdominal pain. Intussusception appeared in three patients (27.3%). Contrary to the medical literature, the symptomatic lipomas were preferentially situated in left colon and its mean size was 6.1 cm. The diagnosis were performed through opaque enema and more recently by colofibroscopy and CT scan. Resections were performed in all patients: five were enlarged, three were local and other three were endoscopic resections. Multiple lipomas were detected in 30% of patients who were submitted to necropsy and in 25% of asymptomatic group. In both groups no tumor was larger than 2.0 cm of diameter. CONCLUSIONS: Colorectal lipomas are rare in both clinical presentation and necropsy. Before the advent of CT scan and colofibroscopy the majority of the patients were submitted to wide resections, in the assumption of malignancy. Afterwards the endoscopic polipectomy and local resection became our preferential management.