Tocilizumab-Induced Erythema Annulare Centrifugum.

We report the case of a 42-year-old woman with rheumatoid arthritis undergoing treatment with subcutaneous tocilizumab for the past 6 months. Three days after the administration, an asymptomatic inflammatory annular plaque of 4 cm with discrete whitish scales at the inner border margin developed at the injection site in the left iliac fossa. A smaller plaque in the left groin appeared soon after. The mycological exam was negative. Histology showed a lymphoplasmacytic superficial and deep perivascular, and periadnexal, dermal infiltrate, without epidermal changes. Lesions spontaneously regressed in 4 months. The diagnosis was clinically and histologically consistent with erythema annulare centrifugum, following the exclusion of other differential diagnoses. Erythema annulare centrifugum represents a delayed-type hypersensitivity reaction generally considered idiopathic or otherwise related to numerous triggers, including drugs such as biologics. We describe the first reported case of tocilizumab-induced erythema annulare centrifugum. This case should alert dermatologists to this relatively rare and complex entity and should raise awareness to cutaneous biologic drug reactions.

Rare Condition, Unusual Anatomy, Elegant Solution - an Uncommon Manifestation of Kawasaki Disease.

INTRODUCTION: Peripheral artery aneurysms are a rare manifestation of Kawasaki disease (KD), with an estimated incidence of approximately 2% of all KD patients. The case of a 14-year-old girl with past clinical history suggestive of KD is reported; she presented with an aneurysm located in the brachial part of a superficial brachioulnoradial artery, still with the genuine brachial artery in place (an anatomical variation with a reported incidence of 0.14-1.3% in general population). Relevant medical data were collected from the hospital database. REPORT: This is a report of a case of a symptomatic superficial brachioulnoradial artery aneurysm, secondary to KD, treated with aneurysm exclusion and superficial brachioulnoradial to the genuine brachial artery transposition. Uneventful intra- and postoperative course with symptom resolution is reported. DISCUSSION: The coexistence of a rare manifestation of KD (peripheral aneurysm) with an even rarer brachial artery variation allowed a simple but elegant solution, making this a unique case.

SEEG initiative estimates of Brazilian greenhouse gas emissions from 1970 to 2015.

This work presents the SEEG platform, a 46-year long dataset of greenhouse gas emissions (GHG) in Brazil (1970-2015) providing more than 2 million data records for the Agriculture, Energy, Industry, Waste and Land Use Change Sectors at national and subnational levels. The SEEG dataset was developed by the Climate Observatory, a Brazilian civil society initiative, based on the IPCC guidelines and Brazilian National Inventories embedded with country specific emission factors and processes, raw data from multiple official and non-official sources, and organized together with social and economic indicators. Once completed, the SEEG dataset was converted into a spreadsheet format and shared via web-platform that, by means of simple queries, allows users to search data by emission sources and country and state activities. Because of its effectiveness in producing and making available data on a consistent and accessible basis, SEEG may significantly increase the capacity of civil society, scientists and stakeholders to understand and anticipate trends related to GHG emissions as well as its implications to public policies in Brazil.

[Percutaneous Endovascular Aortic Repair with Local Anesthesia - One Day Surgery]. / Tratamento Endovascular do Aneurisma da Aorta Abdominal por Via Percutânea e Anestesia Local ­ One Day Surgery.

INTRODUCTION: To evaluate the results of the abdominal aortic aneurism endovascular treatment (EVAR), percutaneously and with local anesthesia, according to the concept of one day surgery. MATERIAL AND METHODS: Unicentric, retrospective analysis of patients with aorto-iliac aneurysmal disease, consecutively treated by EVAR with percutaneous access trough the Preclose technique (pEVAR), according to the outpatient criteria, with one overnight stay in the hospital. The technical success, exclusion of the aneurysmal sac, endoleak, re-intervention and mortality were evaluated. RESULTS: Twenty consecutive patients (all male; mean age 74.65 years) were treated by EVAR with percutaneous access and local anesthesia, from which 95% (19) presented with abdominal aortic aneurysm and 5% (1) common iliac aneurysm. All implants were sucessfully performed, with an initial endoleak rate of 10% (2), determined by one type 1a endoleak successfully corrected intra-operatively and one type 2a endoleak diagnosed in the first imaging control, which sealed spontaneously on the second control. Initial technical success for percutaneous closure was 97.5%, with one case reported of femoral pseudo-aneurism, posteriorly treated by percutaneous thrombin injection. Median length of stay was one day [1-10], with a mean follow-up of 11.4 months [1-36]. Both the re-intervention and mortality rate are 0% for the selected period. CONCLUSION: Our one day surgery model for the outpatient treatment of abdominal aortic aneurysm by the pEVAR technique is innovative, safe and effective, as long as the selection criteria are respected.

Introdução: Avaliar os resultados do tratamento endovascular do aneurisma da aorta abdominal (EVAR) por via percutânea e anestesia local, segundo o conceito de one day surgery.Material e Métodos: Análise retrospetiva, unicêntrica dos doentes com doença aneurismática aorto-ilíaca, consecutivamente submetidos a tratamento endovascular do aneurisma da aorta abdominal por via percutânea (pEVAR) pela técnica de Preclose, seguindo critérios de ambulatorização com pernoita após o procedimento. O sucesso técnico, exclusão do saco aneurismático, endoleak, reintervenção e tempo de internamento foram avaliados.Resultados: Vinte doentes consecutivos (todos homens, idade média 74,65 anos) foram tratados por pEVAR e anestesia local, dos quais 95% (19) apresentavam aneurisma da aorta abdominal e 5% (1) aneurisma da artéria ilíaca comum. Todos os implantes foram realizados com sucesso, com uma taxa de endoleak inicial de 10% (2), à custa de um endoleak 1a corrigido intraoperatoriamente com sucesso, e um endoleak 2a diagnosticado na primeira angio-tomografia computorizada pós-operatória, que selou espontaneamente no controlo aos 6 meses. O sucesso técnico inicial do encerramento percutâneo foi de 97,5%, com um caso reportado de pseudo-aneurisma femoral, corrigido posteriormente por injeção percutânea de trombina. A mediana de internamento foi de 1 dia [1-10], com follow-up médio de 11,4 meses [1-36]. A reintervenção e mortalidade são de 0% no período descrito. Conclusão: O tratamento ambulatório do aneurisma da aorta abdominal por via endovascular com acesso percutâneo segundo o nosso modelo de one day surgery é inovador, seguro e eficaz, respeitando os critérios de seleção.

Reconstrução torácica com retalhos do músculo reto abdominal e grande dorsal: relato de casos / Chest wall reconstruction using abdominal rectus and latissimus dorsi muscle flaps: case report

INTRODUÇÃO: A reconstrução da parede torácica ainda permanece como um dos grandes desafios da cirurgia plástica reparadora. O presente estudo tem como objetivo apresentar o relato de pacientes submetidos à reconstrução de parede torácica com a utilização de retalhos miocutâneos, após ressecções de parede por tumores/osteomielite. MÉTODOS: Foram incluídos quatro pacientes, três deles portadores de osteomielite e o último apresentando-se com sarcoma, todas as afecções acometendo a parede torácica. Foram submetidos à ressecção de parede e reconstrução com retalhos miocutâneos do grande dorsal (dois casos) e reto abdominal (dois casos). RESULTADOS: Os retalhos utilizados foram suficientes para cobertura cutâneo-muscular e mantiveram boa vitalidade. Em apenas um caso, houve sofrimento parcial do retalho. Não houve recidiva precoce da doença. A estabilidade da caixa torácica foi preservada. CONCLUSÕES: A utilização dos retalhos citados no reparo dos defeitos torácicos mostrou-se satisfatória na intenção de prover revestimento cutâneo e músculo bem vascularizado, este fundamental no combate aos quadros infecciosos locais.

INTRODUCTION: Chest wall reconstruction remains one of the great plastic surgery repair challenges. The present work aims to report on cases of chest wall reconstruction using myocutaneous flaps after wall resection due to tumor/osteomyelitis. METHODS: Four patients were included, among which three presented with osteomyelitis and the other presented with sarcoma; both of these conditions affected the chest wall. Each patient underwent wall resection and reconstruction using myocutaneous flaps from the latissimus dorsi (two cases) and abdominal rectus (two cases). RESULTS: The flaps used were sufficient for skin-muscle covering and maintained good vitality. Partial flap injury occurred in one case. Chest cavity stability was preserved. CONCLUSIONS: The use of the above flaps to repair chest defects was satisfactory with the aim of covering the skin and providing well-vascularized muscles, the latter of which was fundamental to preventing local infection.

Isolated aortitis: a rare cause of febrile illness.

Febrile illness often presents a challenge for the clinician. The main causes of febrile illness are infections, solid or haematological malignancies and connective tissue disorders, including vasculitis. A 49-year-old woman sought medical attention because of intermittent fever that lasted 2 weeks. She presented no further symptoms or physical signs to suggest the aetiology. The epidemiological context was irrelevant. Analyses revealed anaemia of chronic disease and significant elevations of inflammatory parameters. A comprehensive study was performed, which revealed presence of an aortitis. Investigation of infectious and immunological causes was negative. We arrived at the definitive diagnosis of isolated aortitis. She was treated with corticosteroid and methotrexate, with resolution of symptoms and clinical abnormalities.

Inflammatory myopathy and interstitial lung disease in antisynthetase syndrome with PL-7 antibody.

We report a case of a 72-year-old Caucasian woman with PL-7 positive antisynthetase syndrome. Clinical presentation included interstitial lung disease, myositis, 'mechanic's hands' and dysphagia. As lung injury was the main concern, treatment consisted of prednisolone and cyclophosphamide. Complete remission with reversal of pulmonary damage was achieved, as reported by CT scan, pulmonary function tests and functional status.

Nitrofurantoin: cause of DRESS syndrome.

Urinary tract infections (UTIs) are a common pathological entity among elderly patients. The widespread use of antibiotics for uncomplicated UTIs has gained many opponents mainly due to the increasing drug resistance observed. Nitrofurantoin is a commonly used antibacterial drug because it has low side effects and a good antiurinary bacterial profile. However, in this paper, we present a case of a nitrofurantoin-induced DRESS (drug reaction/rash with eosinophilia and systemic symptoms) syndrome in a 77-year-old woman. During UTI treatment, the patient developed an acute skin rash which spread all over the body and a considerable decrease in urine volume. At the emergency department, we found her developing eosinophilic pneumonia, anaemia and renal impairment that we relate to nitrofurantoin administration. To our knowledge, this is the second published case report which evokes nitrofurantoin as a possible cause of DRESS syndrome.

Impacto da reconstrução mamária na qualidade de vida de pacientes mastectomizadas atendidas no Serviço de Cirurgia Plástica do Hospital Universitário Walter Cantídio / The impact of breast reconstruction on the quality of life of patients after mastectomy at the Plastic Surgery Service of Walter Cantídio University Hospital

INTRODUÇÃO: A reconstrução mamária tem por objetivo restabelecer a estética corporal e melhorar a autoimagem da paciente, restaurando o volume perdido e assegurando simetria com a mama contralateral. O objetivo deste trabalho é verificar a qualidade de vida de pacientes mastectomizadas e submetidas a reconstrução mamária imediata ou tardia, abordando os domínios físico, psicológico e social. MÉTODO: Foram estudadas 27 pacientes submetidas a reconstrução mamária no Hospital Universitário Walter Cantídio, entre agosto de 2007 e agosto de 2012. Foi realizado um estudo transversal, com avaliação da qualidade de vida por meio da aplicação do questionário World Health Organization Quality of life (WHOQOL) abreviado. RESULTADOS: As pacientes entrevistadas avaliaram positivamente sua qualidade de vida, com atribuição da nota 4 (boa) por 41% e 5 (muita boa) por 33% das entrevistadas à pergunta "Como você avaliaria sua qualidade de vida?". Dentre as pacientes entrevistadas, 81% foram submetidas a reconstrução imediata e a maioria delas (45%) atribuiu nota 4 (boa) à pergunta "Como você avaliaria sua qualidade de vida?". Por outro lado, 60% das pacientes submetidas a reconstrução tardia atribuíram nota 5 (muito boa) a essa pergunta. CONCLUSÕES: Os resultados demonstram que a reconstrução mamária possibilita à mulher mastectomizada incorporar ao tratamento do câncer de mama conceitos de qualidade de vida, trazendo benefícios físicos, psicológicos e sociais.

INTRODUCTION: The aim of breast reconstruction is to restore body contour and improve the patient's self-image by replacing the volume loss and ensuring proper symmetry with the contralateral breast. This study evaluated the quality of life and physical, psychological, and social aspects of patients who underwent mastectomy and immediate or delayed breast reconstruction. METHODS: Twenty-seven patients underwent breast reconstruction at Walter Cantídio University Hospital between August 2007 and August 2012. The World Health Organization Quality of Life survey was used to conduct a cross-sectional study to evaluate patient quality of life. RESULTS: The patients positively evaluated their quality of life. A score of 4 (good) and 5 (very good) was assigned by 41% and 33% of women, respectively, to the question "How would you rate your quality of life?" Among the patients, 81% underwent immediate reconstruction and most (45%) assigned a score of 4 (good) to the question "How would you evaluate your quality of life?" A total of 60% of patients who underwent delayed reconstruction attributed a score of 5 (very good) to this question. CONCLUSIONS: These results demonstrate that breast reconstruction after mastectomy results in good or very good quality of life and is associated with physical, psychological, and social benefits.

Abdominal compartment syndrome after endovascular repair of ruptured iliac artery aneurysm.

Abdominal compartment syndrome is a possible complication after aneurysm repair and has a high mortality rate. Although there has been an increment in patient survival rates after aneurysm repair, there has also been an increase in this entity. However, there are few data about the incidence and management of this complication after endovascular repair of a ruptured iliac artery aneurysm. The objective of this report is to describe a case of abdominal compartment syndrome after endovascular correction of a ruptured iliac artery aneurysm, emphasizing the importance of the accurate monitoring of intra-abdominal pressure, medical therapy and timely laparotomy. An 85-year old male was submitted to the endovascular repair of a ruptured iliac artery aneurysm. On the first day after the intervention, he developed abdominal compartment syndrome which did not resolve with medical therapy. Consequently, on the second postoperative day, a decompressive laparotomy was performed, removing the retroperitoneal haematoma, which was the main cause of the high intra-abdominal pressure and the abdominal compartment syndrome. At 12 months of follow-up, there was no evidence of complications. This case stresses the importance of early recognition of abdominal compartment syndrome.

Dorsal prevertebral lesions in Wegener granulomatosis: report on four cases.

Retroperitoneal fibrosis has been reported in several patients with Wegener granulomatosis (WG), but only three isolated cases of dorsal prevertebral lesions, closely resembling fibrosing mediastinitis, have been published so far. We describe four new WG patients (two men, two women), 49-59 years old at diagnosis, with dorsal prevertebral lesions, mainly right-sided, and with adjacent pleural thickening in two. These lesions were detected on computed-tomography scans at diagnosis in two patients, and occurred later in the two others. Only one of them had mild back pain. Two patients' lesions were biopsied, revealing granulomatous inflammation. In one patient, the lesion regressed under WG treatment. Lesion size did not change in the remainings. Intralesional calcifications appeared in two. None of the patients had local bone erosion, vascular or neurological complications. These prevertebral lesions might represent a dorsal form of retroperitoneal fibrosis in WG, but usually with a more benign presentation and course. WG should be included in the differential diagnosis of fibrosing mediastinitis (with tuberculosis, neoplastic diseases, sarcoidosis, histiocytosis and inflammatory pseudotumor), which may have a similar radiological appearance.

Isolated iliac artery aneurysms: six-year experience.

OBJECTIVES: To review the experience of our institution in repairing isolated iliac artery aneurysm (isolated IAA) in the last six years. METHODS: The medical records of patients who underwent isolated IAA repair were reviewed, to obtain information on patients' demographics, vascular risk factors, type of treatment and outcome. RESULTS: A total of 11 patients with 16 aneurysms, all men, with a mean age of 69.2+/-6.0 years were treated. The mean diameter was 3.7+/-1.0 cm (3.5+/-1.1 cm at elective repair; 5.7+/-2.9 cm on the emergency cases). The majority of aneurysms were at the common iliac artery and 27.3% of them were multiple. The diagnosis of multiple aneurysms was performed 10 years later, compared with the mean age of the diagnosis of single aneurysms, and this difference is statistically significant. Seven (63.6%) had elective operations, and one elective endovascular repair. Analysing the vascular risk factors, it was evident that hypertension was the most prevalent and the diagnosis of aneurysm was done 10 years sooner in the smoker patients. There was no postoperative death in this series. The mean follow-up period was of 21 months, and during it, one patient developed a non-infection anastomotic aneurysm of common femoral artery, one died with a myocardial infarction, one presented with limb graft thrombosis and another was lost. CONCLUSION: This series contributes to a better characterization of a rare pathology demonstrating that both surgical and endovascular treatment can be performed with very low morbidity and mortality.

Providing integrity and authenticity in DICOM images: a novel approach.

The increasing adoption of information systems in healthcare has led to a scenario where patient information security is more and more being regarded as a critical issue. Allowing patient information to be in jeopardy may lead to irreparable damage, physically, morally, and socially to the patient, potentially shaking the credibility of the healthcare institution. Medical images play a crucial role in such context, given their importance in diagnosis, treatment, and research. Therefore, it is vital to take measures in order to prevent tampering and determine their provenance. This demands adoption of security mechanisms to assure information integrity and authenticity. There are a number of works done in this field, based on two major approaches: use of metadata and use of watermarking. However, there still are limitations for both approaches that must be properly addressed. This paper presents a new method using cryptographic means to improve trustworthiness of medical images, providing a stronger link between the image and the information on its integrity and authenticity, without compromising image quality to the end user. Use of Digital Imaging and Communications in Medicine structures is also an advantage for ease of development and deployment.

Upper limb ischemia in a patient with Wegener's granulomatosis.

OBJECTIVES: We report a clinical case of a small-vessel vasculitis with ischemia of the left upper limb. CASE: A patient diagnosed with Wegener's granulomatosis and involvement of the left axillary and brachial arteries. A left axillary-radial bypass with reversed left great saphenous vein was performed. RESULTS: After a period of 36 months of follow-up the patient is asymptomatic with complete healing of the trophic lesions. CONCLUSION: Classic Wegener's granulomatosis is a form of vasculitis that primarily involves the upper and/or lower respiratory tract and kidney. The amount of clinical symptoms is enormous and the diagnosis, arduous. In the literature there are only a few clinical cases referring to limb ischemia in a setting of Wegener's granulomatosis. This is a unique case report of upper limb ischemia due to involvement of a medium-large size artery in a patient with Wegener's granulomatosis.

Papel da excisão total do masorreto no tratamento multimodal do câncer de reto / Role of total mesorectal excision in multimodal treatment of rectal cancer

O tratamento do câncer de reto vem apresentando inúmeros avanços nas últimas décadas. Os altos índices de recidiva local estavam associados a uma sobrevida inadequada. Após a aquisição de uma série de recursos técnicos que aumentaram a preservação esfincteriana, uma modificação técnica proposta por Heald, em 1982, denominadade excisão total do mesorreto (ETM) proporcionou uma redução da recorrência local de 20 por cento a 40 por cento para menos de 10 por cento. Nesta revisão, foram avaliados os princípios, resultados e complicações da ETM num cenário em que aquimioirradiação neo-adjuvante para tumores nos estádios II e III também tem papel fundamental no controle local e na sobrevida destes pacientes.

Initial experience in Brazil with endoscopic submucosal dissection for early gastric cancer using insulation-tipped knife: a safety and feasibility study.

BACKGROUND: Endoscopic resection is an adequate treatment for subgroups of patients with early gastric cancer. Endoscopic submucosal dissection (ESD) represents a recent advance and leads to good results when adequately indicated. There is great experience with this technique in Japan and it is gaining acceptance among Western endoscopists. We present the first gastric ESD series performed in Brazil. METHODS: Patients with well-differentiated adenocarcinomas macroscopically classified as early cancer, less than 30 mm with no ulcer or scar, were included. ESD was performed with an insulated-tip knife and electrosurgical unit with endocut mode. Clinicopathological aspects and morbidity were evaluated. The study was approved by the local ethics committee and informed consent was obtained from all participant subjects. RESULTS: From October 2005 to July 2007, 160 patients received surgical treatment for gastric cancer; 44 patients (27.5%) had early gastric cancer. In this latter group, 15 procedures (ESD) were performed in 12 patients. The mean size of the lesions was 16.8 mm. Almost half of the lesions were located in the proximal third of the stomach and the mean elapsed time for the procedure was 140 min. In 80% of the cases resection was en bloc and 80% of the resections were considered curative. We had three perforations, which were managed clinically, and no bleeding. CONCLUSION: When adequately indicated, ESD is a safe and feasible technique.

D2 lymphadenectomy with para-aortic sampling improves lymph node staging for gastric cancer / Linfadenectomia D2 com amostragem para-aórtica melhora o estadiamento linfonodal do câncer gástrico

BACKGROUND: An important aspect dealing with gastric cancer is the role of lymphadenectomy in gastric cancer staging. AIM: To verify if lymphadenectomy with stations separation increases the number of dissected lymph nodes and establish comparison between TNM 2002 and JGCA 1998 evaluating lymph nodal status (N). METHODS: This is a retrospective analysis of the patients that underwent curative gastrectomy and D2 dissections for adenocarcinoma between 2004 and 2006. Between January of 2004 and June of 2005 (group 1), lymphadenectomy was performed en-bloc with gastrectomy and only TNM system was used. After June of 2005 (group 2), the surgeon himself dissected lymph nodal stations, allowing use of TNM and JGCA systems. Studied aspects were age, Borrmann classification, histological grade, venous or lymphatic invasion, depth of invasion, peritoneal cytology and type of gastrectomy. End points were number of dissected lymph nodes, number of positive lymph nodes and agreement between staging systems. Chi-square test and T-test were used for statistical analysis. RESULTS: One hundred forty-five gastrectomies were performed, 76 in group 1 and 69 in group 2. In group 1, mean age was of 61 years and 59 years in group 2 (P=0,12). Eighty per cent of tumors were advanced in both groups. Venous or lymphatic invasion and positive peritoneal cytology were more frequent in group 1, 65.6% vs 35,3% (P= 0,001) e 13.9% vs 3.1% (P=0,03), respectively. Borrmann classification, histological grade, Lauren classification and type of gastrectomy were not different between the groups. In group 1, mean number of lymph nodes was 32,7 and 37,35 in group 2 (P= 0,09). Rates of positive lymph nodes in groups 1 and 2 were 72.2% and 53%, respectively (P= 0,02). Migration analysis of lymph node status (N) realized only in group 2 (69 patients) showed agreement between TNM and JGCA in 50 patients (72,5%). Using JGCA system, modification in 19 patients occurred (27,5%), with upstaging in 13 (18,8%) and downstaging in six (8,7%). CONCLUSION: In this study, a tendency of increase in number of lymph nodes was verified when the surgeon himself dissected lymph nodal stations. JGCA system modified the lymph nodal staging in comparison to TNM system in 30% of all cases.

RACIONAL: O papel da linfadenectomia no estadiamento de câncer gástrico é de grande importância quando lidando com câncer gástrico. OBJETIVO: Verificar se a linfadenectomia com estações linfonodais separadas aumenta o número da dissecção de linfonodos e estabelecer comparação entre o TNM 2002 e o JGCA 1998, avaliando o status dos linfonodos (N). MÉTODOS: Foi realizada análise retrospectiva de pacientes que foram submetidos à gastrectomia curativa e dissecções do tipo D2 para adenocarcinomas, entre 2004 e 2006. Entre janeiro de 2004 e junho de 2005 (grupo 1), a linfadenectomia foi realizada em flape único com gastrectomia e somente o sistema TNM foi utilizado. Após junho de 2005 (grupo 2), o cirurgião realizou a dissecção de estações linfonodais, permitindo o uso dos sistemas TNM e JGCA. Os aspectos estudados e analisados foram idade, classificação de Borrmann, grau histológico, invasão venosa ou linfática, profundidade da invasão, citologia peritoneal e tipo de gastrectomia. Foram analisados o número de linfonodos dissecados, o número de linfonodos positivos e o entendimento entre os sistemas de estadiamento. O teste do Chi-quadrado e teste-t foram utilizados para realizar a análise estatística. RESULTADOS: Foram realizadas 145 gastrectomias, sendo 76 no grupo 1 e 69 no grupo 2. A idade média referente ao grupo 1 foi de 61 anos e de 59 no grupo 2 (P=0,12). Em ambos os grupos 80% dos tumores eram avançados. Invasão venosa e linfática e citologia peritonial positiva foram mais freqüentes no grupo 1, 65.6% vs 35.3% (P=0,001) e 13.9% vs 3.1% (P=0,03), respectivamente. A classificação de Borrmann, grau histológico, classificação de Lauren e tipo de gastrectomia não foram diferentes entre os grupos. No grupo 1, a média de linfonodos foi de 32.7 e no grupo 2 de 37.35 (P=0,09). O índice de linfonodos positivos nos grupos 1 e 2 foi de 72.2% e 53%, respectivamente (P=0,02). A análise de migração do status de linfonodos (N) foi realizada no grupo 2 (69 pacientes) em concordância com o TNM e JGCA em 50 pacientes (72.5%). Ao utilizar o sistema JGCA, ocorreram modificações em 19 pacientes (27.5%), com aumento de estadiamento em 13 (18.8%) e diminuição em 6 (8.7%). CONCLUSÃO: Neste estudo, foi verificada tendência ao aumento do número de linfonodos quando o cirugião realizou, ele mesmo, a dissecção das estações linfonodais. O sistema JGCA modificou o estadiamento linfonodal quando comparado ao sistema TNM em 30% de todos os casos.

Percutaneous endoscopic gastrostomy in advanced head and neck cancer / Gastrostomia endoscópica percutânea em pacientes com tumores avançados de cabeça e pescoço

BACKGROUND: Percutaneous endoscopic gastrostomy performed as proposed by Gauderer et al. in 1980, has been used quite frequently in patients with head and neck tumors. Some authors believe that this so-called pull technique would be associated to the risk of a tumor implantation in the wound as well as high levels of peristomal wound infection. Although some alternative techniques provide better results, doubts about their technical applicability in daily practice still persists. AIM: To assess the feasibility, safety and morbidity of percutaneous endoscopic gastrostomy performed through a well-defined and standardized technique in patients with nonresectable or advanced head and neck cancer. METHODS: A consecutive series of patients who had either nonresectable or advanced tumors and were unable to be fed orally were submitted to an oncologic-hospital-based tertiary-referral endoscopy practice. Tubes were implanted through an introducer technique comprised of two main stages. The first consisted of the application of two stitches aiming to fixate the anterior gastric wall to the abdominal wall, and the second being the inserting of the gastrostomy tube. RESULTS: Between February 2003 and May 2004, 129 percutaneous endoscopic gastrostomies were performed. This study included 60 patients. They were all able to receive food on the same day. Operative morbidity was observed in six patients (10%) and one procedure-related mortality was also observed (1.6%). CONCLUSION: Percutaneous endoscopic gastrostomy is both feasible and safe, associated to low morbidity, and to acceptable mortality rates.

RACIONAL: A gastrostomia endoscópica percutânea executada conforme a técnica proposta por Gauderer et al., em 1980, tem sido freqüentemente utilizada em pacientes com tumores de cabeça e pescoço. Diversos autores relatam que ela, conhecida como técnica de “puxar”, está associada a risco de implante de tumor na parede abdominal assim como risco bastante elevado de infecção na ferida operatória. Algumas variantes técnicas proporcionam melhores resultados, contudo existem dúvidas acerca da sua viabilidade técnica na prática diária. OBJETIVO: Verificar a exeqüibilidade, segurança e morbidade da gastrostomia endoscópica percutânea realizada por técnica padronizada e bem definida em pacientes com tumores avançados ou irressecáveis da cabeça e pescoço. MÉTODO: É descrita série consecutiva de pacientes com tumores avançados ou irressecáveis de cabeça e pescoço, incapazes de receber dieta por via oral, submetidos à gastrostomia endoscópica percutânea no setor de endoscopia digestiva de um hospital oncológico de referência terciária. As sondas foram implantadas pela técnica de punção compreendida de duas etapas principais. A primeira, consistiu na aplicação de dois pontos transfixantes com o propósito de fixar a parede anterior do estômago à parede abdominal. A segunda, introdução do tubo de gastrostomia por punção percutânea. RESULTADOS: Foram realizadas 129 gastrostomias endoscópicas percutâneas e incluiu 60 pacientes. Todos foram liberados para receber dieta no mesmo dia. Morbidade operatória ocorreu em seis pacientes (10%) e mortalidade relacionada ao procedimento foi verificada em um paciente (1,6%). CONCLUSÃO: A gastrostomia endoscópica percutânea é exeqüível e segura, além de estar associada à baixa morbidade e aceitável mortalidade.