Cost-effectiveness analysis of 3D versus 2D transesophageal echocardiography for the evaluation of patients with primary mitral regurgitation with indication of surgical treatment

OBJECTIVES: To perform the cost-effectiveness analysis of three-dimensional transesophageal echocardiography (3DTEE) in comparison to two-dimensional transesophageal echocardiography (2DTEE) for the anatomic-functional evaluation and surgical planning of severe primary mitral regurgitation. METHODS: a complete economic study was based on a systematic review of 3DTEE and 2DTEE accuracy and private health system costs of two different surgical interventions: mitral valve plasty and mitral valve replacement. The prevalence of common postoperative complications was also predicted for elective procedures: atrial fibrillation (8.6%); acute myocardial infarction (1.4%); thrombosis (3.5%); bleeding (1.5%); endocarditis (6.3%). The decision tree method was adopted as a data analysis model. The Bayes" theorem was used based on sensitivity and specificity measurements. The costs, considering literature and professional tables, were: 3DTEE = US$ 349; 2DTEE = US$ 204; diagnostic evaluation = US$ 597; surgical procedure = US$ 3,643; surgical treatment = US$ 374. RESULTS: The deterministic analysis of the diagnostic test shows that 3DTEE (non-dominated) is superior to 2DTEE (absolutely dominated). The 3DTEE presents a cost reduction of US$ 1,147 and incremental effectiveness (true identification) of 22% when compared to 2DTEE. The multivariate probabilistic sensitivity analysis showed that after 100,000 iterations, the diagnosis based on the 3DTEE becomes the first choice regardless of the willingness to pay threshold. CONCLUSIONS: 3DTEE was cost-effective compared to 2DTEE. Thus, 3DTEE is a potential device to promote health compared to 2DTEE for surgical planning of severe primary mitral regurgitation. (AU)

[Gastrointestinal bleeding] / Hemorragia digestiva.

OBJECTIVE: To present an analysis of the occurrence of gastrointestinal bleeding in children and emphasize: i) diagnostic methods; ii) the organized use of different therapeutic approaches in upper gastrointestinal bleeding; iii) the review of concepts, classifications and techniques used in endoscopy, which are important to the practice of clinical pediatrics. METHODS: Literary review of chapters selected from textbooks, pertinent articles obtained through the Medline system and active search, as well as personal archives belonging to the authors. RESULTS: The differential diagnosis of gastrointestinal bleeding in children varies according to the age. The causes of upper gastrointestinal bleeding are subdivided into variceal and nonvariceal. Nonselective beta-blockers are recommended to prevent variceal bleeding. Vasoactive drugs, such as somatostatin, octreotide, and glypressin may be used, showing good results in both variceal and nonvariceal acute bleeding. Both sclerotherapy and variceal ligation can be used in children to achieve variceal eradication. Cyanoacrylate is effective and presents the lowest complication rate related to gastric variceal bleeding. The presence of hemorrhage stigmata, such as active bleeding and visible vessel in ulcers is indicative of a higher risk for recurrent bleeding, suggesting the need for endoscopic hemostasis. Proton pump inhibitors are more efficacious than H2-receptor antagonists to promote the peptic ulcer healing. CONCLUSION: The correct etiologic diagnosis of gastrointestinal bleeding in children is fundamentally important to adopt the adequate therapeutic approach, whose main advances concern the pharmacological and the endoscopic treatment.

[Biliary fistula after elective conventional cholecystectomy]. / Fístula biliar após colecistectomias convencionais eletivas.

The use or not of drainage after elective cholecystectomy has been recently studied, and we will discuss the real incidence of the subhepatic biliary collection and its clinical significance. In this sense, we studied 20 patients with a mean age of 45 years (4 male and 16 female), submitted to elective cholecystectomy according to selective techniques patterned by our group, where we realized ligature of all vessels of the gallbladder bed, and subhepatic drainage. These patients receibed 99 mTc-DISIDA at the moment we closed the abdomen, and in a period of 24 and 48 hours we studied its presence in the subhepatic bed and in the drainage material. All the patients had not post-operative complications and none biliary drainage or subhepatic collection scanned. We concluded that using our preconized techniques, the subhepatic drainage is unnecessary after elective cholecystectomy.

[Hepatic artery aneurysm: treatment with left hepatectomy. Report of a case]. / Aneurisma da artéria hepática: tratamento pela hepatectomia esquerda. Relato de caso.

A 71-year-old female with a rupture of left intrahepatic artery aneurysm with acute upper abdominal pain, weight loss and fever. The diagnosis was established with doppler ultrasound, contrasted abdominal computer tomography scanning and celiac and mesenteric artery angiography. Prompt recognition and left hepatectomy led to a favourable outcome.

[Total regression of advanced gastric lymphoma after drug therapy]. / Regressão total de linfoma gástrico avançado após quimioterapia.

Primary gastric lymphoma is a relatively rare entity that may have several different methods of treatment, including surgery, chemotherapy and radiotherapy. We describe a case of advanced primary gastric lymphoma treated with chemotherapy. A 51-year-old male patient underwent total gastrectomy after two cycles of chemotherapy. The histologic examination of the gross specimen revealed total regression of the lymphoma. Literature review of this condition and a discussion about the diagnosis and treatment are presented.

[Pseudotumor of the stomach: study of 10 cases and review of the literature]. / Pseudo tumor de estômago: estudo de dez casos e revisão da literatura.

Pseudotumoral form of gastric ulcer is an infrequent clinical presentation of peptic disease. We present the findings in ten patients with this variety of gastric peptic ulcer treated in the last five years. All records including preoperative radiological and endoscopic examinations are reviewed. Five patients were women and five were men. The median age of patients was 62.1 years (range, 45 to 79 years). Epigastric pain was the main symptom in 90% of patients and weight loss in 70%. Six patients underwent surgical treatment. There was no perioperative mortality. A review of literature of this condition and a discussion about the differential diagnosis are presented.

[Duodenal perforation following endoscopic papillotomy: report of 3 cases]. / Perfuração duodenal pós-papilotomia endoscópica: relato de três casos.

Duodenal perforation is a rare complication of endoscopic sphincterotomy and its treatment is controversial. The authors report three cases of duodenal perforation by endoscopic sphincterotomy. In two cases with history of a previous biliary infection, surgical treatment had to been performed because of a peripancreatic abscess.