[Hepatosplenic schistosomiasis portal hypertension: effect of esophagogastric devascularization with splenectomy on the diameter and mean flow velocity in the portal system (ultra-sonographic Doppler]. / Hipertensão portal por esquistossomose mansônica hepatoesplênica: efeito da desconexão ázigo-portal com esplenectomia no diâmetro e na velocidade média de fluxo do sistema portal (estudo ultra-sonográfico com Doppler).

BACKGROUND: Esophagogastric devascularization with splenectomy has been used for the treatment of upper digestive bleeding due to esophagic varices in hepatoportal mansoni's schistosomic portal hypertension. Nevertheless, early portal thrombosis has hampered this surgical technique (13.3% and 53.2%), compromising the good results on the hemorrhagic side. Supposing that portal circulatory changes, due to the surgical treatment, may play an important role in this kind of complication, our objective was to identify the hemodynamic facilitating factors. Portal hemodynamic aspects, identified by ultra-sonographic Doppler study, from two groups of patients: non-operated upon and splenectomized with esophagogastric devascularization in late post-operatory phase (in excess of 6 moths), with portal hypertension due to mansoni hepatoesplenic portal hypertension and in similar clinical conditions, were compared. METHOD: Fifty eight ambulatorial patients were studied, all had portal hypertension caused by mansoni's hepatosplenic schistosomiasis and previous bouts of digestive bleeding. They were divided in two groups: A--29 followed clinically/endoscopically, and group B--29 previously submitted to esophagogastric devascularization with splenectomy. In all was measured the diameter and mean flow velocity in the portal vein and its right and left branches by ultra-sonographic Doppler study. The results were submitted to statistical analysis for inter- and intra-group comparison. RESULTS: Group A (non-operated): the portal vein diameter was greater than the right and left branches (10.6 +/- 2.9, 8.0 +/- 1.8, 9.1 +/- 2.6 cm), the mean flow velocities in the portal vein and its branches were similar (15.62 +/- 6.17, 14.92 +/- 5.33, 16.12 +/- 4.18 cm/seg). Group B (operated): the diameter and mean flow velocity in all vessels were reduced (8.8 +/- 1.7, 5.2 +/- 1.2, 7.5 +/- 2.2 cm/12.53 +/- 2.60, 8.86 +/- 1.75, 9.69 +/- 3.75 cm/seg). CONCLUSIONS: After esophagogastric devascularization with splenectomy, there was a reduction of the diameter and mean flow velocity in the portal vein, its right and left branches.

[Patent paraumbilical vein: hemodynamic importance in Mansoni's hepatosplenic portal hypertension (Study with ultrasonography Doppler]. / Veia paraumbilical pérvia: importância hemodinâmica na hipertensão portal por esquistossomose mansônica hepatoesplênica. (Estudo com ultra-sonografia Doppler).

BACKGROUND: The hemodynamical effect of the collateral portosystemic circulation upon the portal system has not yet been fully understood. The US-Doppler made possible the non-invasive study of the portal system by evaluating the parameters: flow direction, diameter and flow velocity in it's vessels. AIMS: To study the paraumbilical vein as a collateral portosystemic pathway and identify patterns for appraising its hemodynamic importance to the portal system. METHOD: US-Doppler study of the portal system of 24 patients with Mansoni's hepatosplenic schistosomic portal hypertension, previous esophagic variceal bleeding and patent paraumbilical vein with hepatofugal flow. The diameter and the mean flow velocity were measured in the paraumbilical vein and so were the mean flow velocity in the portal vein, right and left portal branches. The Pearson test (linear correlation) was applied to the portal vein's mean flow velocity and the paraumbilical vein's diameter and mean flow velocity. The patients were divided in four groups: D1-paraumbilical vein with diameter < 0.68 cm (n = 14), D2-paraumbilical vein with diameter > or = 0.68 cm (n = 10), V1-paraumbilical vein with mean flow velocity < 18.41 cm/seg (n = 13) and V2-paraumbilical vein with mean flow velocity > or = 18.41 cm/seg (n = 11). The mean flow velocity in the portal vein, right and left portal branches of the four groups were compared. RESULTS: The paraumbilical vein diameter was 0.68 +/- 0.33 cm (range: 0.15-1.30 cm) and the mean flow velocity was 18.41 +/- 11.51 cm/seg (range: 5.73-38.20 cm/seg). The linear correlation between the portal vein's mean flow velocity/paraumbilical vein diameter and the paraumbilical vein's mean flow velocity showed r = 0.504 and r = 0.735, respectively. In the group D2 there was an increase in the mean flow velocity in the portal vein (17.80 +/- 3.42/22.30 +/- 7.67 cm/seg) and in the left portal branch (16.00 +/- 4.73/22.40 +/- 7.90 cm/seg). In the group V2 there was an increase in the mean flow velocity in the portal vein (16.31 +/- 3.49/21.96 +/- 5.89 cm/seg) and in the left portal branch (14.22 +/- 4.41/21.94 +/- 7.20 cm/seg). There was no change in the right portal branch (13.67 +/- 5.74/15.43 +/- 3.43 cm/seg). CONCLUSIONS: In portal hypertension due to hepatosplenic schistosomiasis, the patent paraumbilical vein, with hepatofugal flow, diameter > or = 0.68 cm and mean flow velocity > or = 18.41 cm/seg causes an increase of the mean flow velocity in the portal vein and left portal branch. The best US-Doppler parameter to appraise the paraumbilical vein influence upon the portal system is the mean flow velocity. The correlation between the increase in portal vein's mean flow velocity is stronger with the paraumbilical vein's mean flow velocity than with its diameter. The increase in the portal vein's and left portal branch's mean flow velocity may be understood as the paraumbilical vein's hemodynamic influence upon the portal system. An active portosystemic collateral pathway increases the mean flow velocity in the vein's segment proximal to its point of origin.

[Intrahepatic transtumoral arteriovenous fistulae (diagnosis, importance, therapeutic proposals)]. / Fístulas arteriovenosas intra-hepáticas transtumorais (diagnóstico, importância e propostas de tratamento).

The authors present the angiographic aspects of four patients having an arteriovenous transhepatic transtumoral fistula (two arterioportal and two arteriovenous). The angiographic results of the occlusion with cyanoacrylate (Hystoacryl) of the right hepatic artery in one and by the infusion of Lipiodol in two are also shown. The physiopathological characteristics of each kind of fistula are discussed and the consequences of the passage of the quimioembolizing mixture through the tumor, regarding intrahepatic abscess formation, irregular clinical results and pulmonary complications are commented. These complications make the diagnosis of a transtumoral transhepatic arteriovenous fistula, previously to the chemoembolic treatment important, even though being frequently difficult, because of the reduced caliber of the feeding artery and eventual low transfistular bloodflow. The efficient occlusion of the arterioportal fistula with Histoacryl was favourably compared to the infusion of Lipiodol, which was unable to occlude the arteriovenous fistula. The contraindication to perform chemoembolic treatment of hepatic tumors, when an intrahepatic transtumoral arteriovenous fistula is present and the embolization of the fistular feeding artery is stressed. Ultrasonography using color Doppler and sono-enhancing contrast is appointed as the ideal non-invasive means of making the diagnosis of an hepatic transtumoral fistula and makes it eligible to be the first test in the algorithm for the appraisal of hepatic tumors.

[Acute appendicitis. Experimental model in rabbits]. / Apendicite aguda. Modelo experimental em coelhos.

The evolving phases of acute appendicitis were studied experimentally. Sixty female rabbits (Oryctogalus cuniculus) of New Zealand lineage weighing about 2510 to 3040 g were divided in two groups: a control group and experimental group. The experimental group was divided into three subgroups for observation after 12, 24 and 48 hours of the operation, that consisted on a 4-0 polypropylene circular suture at 8 cm from the distal part of the cecal appendix. The control group was sham operated. The macroscopic exam (increase of the appendix volume, necrosis, perfuration, adherence and secretion in the abdominal cavity) and the microscopic finding showed a progression in the anatomopathological alterations. There was a close relationship between the histopathological findings and time after the appendiceal obstruction. We conclude that the method causes acute appendicitis and that the anathomo pathological alterations depends on the time elapsed between the operation and the postoperation findings.

[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.

[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.

Perianal diseases in HIV-positive patients compared with a seronegative population.

PURPOSE: The aim of this report was to present our cases showing the prevalence and cause of perianal diseases in human immunodeficiency virus-positive patients. METHODS: We compared 1,860 human immunodeficiency virus-positive patients to 1,350 human immunodeficiency virus-negative outpatients with perianal diseases, examined from January 1989 to December 1996, and the results obtained with the treatment methods for seropositive patients. Among them, 88.7 percent were males, mostly in the age range from 30 to 50 years old. RESULTS: Condylomas, ulcers, hemorrhoids, fistulas, fissures, abscesses, and tumors were the most frequently diagnosed diseases. Two or more anal diseases occurred in 16.7 percent of patients. Among the human immunodeficiency virus-negative patients we noticed the same incidence of gender, and most were in the age range of 40 to 60 years old. Hemorrhoids, fistulas, skin tags, and fissures were diagnosed. CONCLUSIONS: From statistical analysis we may conclude that human immunodeficiency virus-positive patients have more condylomas, ulcers, tumors, fistulas, and abscesses than human immunodeficiency virus-negative patients, who have more hemorrhoids. Incidence of fissures was similar in the two groups.

[Atherosclerotic stenosis of the main branches of abdominal aorta. (Prevalence in patients with lower limb occlusive vascular disease)]. / Estenose aterosclerótica dos principais troncos arteriais da aorta abdominal. (Prevalência em pacientes com arteriopatia oclusiva dos membros inferiores).

The authors present the radiographical study of the aortographies of 100 consecutive patients with symptomatic atherosclerotic ischemia of the lower limbs in whom were appraised the stenosis of the celiac trunk, superior mesenteric artery, renal arteries and the presence of the inferior mesenteric artery. The parameters observed were: age, sex, solitary and concomitant stenosis. Seven patients were excluded: six because of arteritis and one because could not be analyzed. Sixty four (68.81%) of the remaining 93 patients had important stenosis (> 30%) of one or more branches of the abdominal aorta, which had a steep raise in number from the 60 decade on. There was no difference regarding to the sex of the patients. The more frequently found solitary stenosis was that of the celiac trunk (16-16.1%) followed by the renal (13-13.0%) and in the concomitant was that of the celiac trunk/renal artery (8-8.6%) and celiac trunk/superior mesenteric artery (5-5.3%). They conclude that in spite of the great number of stenosis of the branches of the abdominal aorta in this kind of patients, there was a low incidence of the concomitant stenosis of the celiac trank/superior mesenteric artery, being difficult to characterize radiologically the digestive ischemic syndrome. They point out that this highly selected group of patients, because of their basic disease, should be more extensively studied in order to identify the results of those vascular stenosis on their digestive tract and orient its eventual treatment.

Healing after anal fistulotomy: comparative study between HIV+ and HIV- patients.

PURPOSE: The aim of this work was to compare wound-healing after anal fistulotomy in human immunodeficiency virus (HIV)+ and HIV- patients and to recognize healing parameters in HIV+ patients. METHODS: Sixty patients were treated with fistulotomy for intersphincteric anal fistula. For each patient, we evaluated white blood cell count values, T CD4 counts, Centers for Disease Control and Prevention classification, and healing duration. There were 31 HIV+ patients (7 A2; 1 A3; 7 C1; 6 C2; 10 C3). RESULTS: Seven C3 patients had incomplete healing. Statistically, there was no difference in the healing duration in HIV+ A2, C1, C2, and HIV-negative patients. C3 patients who did heal took longer than other HIV+ patients. T CD4 counts were similar to healed and not healed C3 patients, although healed C3 values of white blood cell counts were higher than not healed C3 values (4,450 and 2,380/mm3). CONCLUSION: After anal fistulotomy, HIV+ C3 patients either had retarded healing or no healing at all. Therefore, we feel that surgery should be done only in emergency cases of anorectal diseases or in patients with more than 3,000 white blood cells/mm3.

The bilobed island flap in nasal ala reconstruction.

A bilobed island flap with an extended subcutaneous pedicle including part of the transverse portion of the elevator muscle of the nasal ala is described. This flap was employed for nasal ala reconstruction in 21 patients following excision of malignancy. The series includes 12 females and 9 males ranging in age from 25 to 83 years. In 19 patients, the reconstruction spared the mucosa layer and in two a skin graft was used under the flap to reconstruct the lining. The flap was viable in all cases and the aesthetic outcome satisfactory. The rotation fold dog ear is eliminated. In planning the BIF the length of its lobes (proximal and distal), should be equal to the defect; the width of the proximal lobe, compared to the defect, and the distal lobe compared to the proximal lobe should be progressively narrower.

[Angiographic aspects of the hepatic veins in portal hypertension in schistosomiasis. The importance in assessing the hepatic vein pressure]. / Aspectos angiográficos das veias hepáticas na hipertensão portal esquistosomótica. (Importância na medida da pressão venosa hepática).

The authors comment upon the importance of the hepatic wedged venous pressure for the appraisal of the circulatory conditions of the portal system, mainly in cirrhotic patients. Wondering about the irregular results obtained in the study of schistosomotic portal hypertensive patients by occlusive catheterization and with the use of an occlusive balloon catheter, noted the scarcity of angiographic studies on the subject in this pathology. Present the angiographic aspects that were obtained from patients with schistosomotic portal hypertension complicated by digestive bleeding, by means of injecting the contrast material into a hepatic vein of the right hepatic lobe via a loosely introduced catheter. Those radiological aspects were distributed in two categories: 1) type I-presenting variable sinusoidal filling. Presence of anastomotic intraparenquimatous communications with or without calibrous anastomotic veins between the hepatic veins, 2) type II-presenting no sinusoidal filling. Presence of multiple anastomotic communications of varied calibers between the hepatic veins. Commenting the difficulty of assessing the wedged pressure in patients with schistosomotic portal hypertension because of the easy communication between the hepatic veins, the authors point out that the measured pressure, in all the cases, will be that of the opposite hepatic vein. That pressure, in this pathology, might represent the sinusoidal resistance (when present) between hepatic veins, instead of relating to the portal vein. Suggestion is made that the measure of the wedged hepatic pressure, in patients with schistosomotic portal hypertension, be appraised considering the angiographic aspects of the hepatic veins.

[Splanchnic portal circulation (enhancement of radiologic image intensity and of visibility of collateral branches with prostaglandin E1)]. / Circulação portal esplâncnica. (Reforço da intensidade da imagem radiológica e aumento da visibilização de colaterais com emprego da prostaglandina E1).

The authors present the results of a comparative study of mesenterico-portographies with and without the use of Prostaglandin E1 (PGE1) injected intrarterially into the superior mesenteric artery as an adjunct to the radiographic procedure. Twenty eight patients, with varied hepatic and biliopancreatic ailments, referred to the Radiologic Department for angiographic appraisal of the splanchnic circulation were studied. Two series of radiographies were realized after catheterization of the superior mesenteric artery: a first after the injection of the contrast only and a second after the injection of 50 micrograms of PGE1 as a bolus prior the contrast means. The difference in opacification of the various segments of the portal system and the lapse of time necessary to attain the maximum radiographic density were appraised. They observed that, with the use of PGE1 was attained a regular, intense and swift opacification of the superior mesenteric vein, portal vein and intrahepatic branches in all patients that had those segments previous and/or hepatotropic circulation. There was a significative reduction in the lapse of time necessary to attain the maximum opacification. Also they observed, with the use of the PGE1, the opacification of collateral branches of the portal system in more patients and intensification in those that were previously opacified. Because of the good results attained with the use of the PGE1, its transitory pharmacologic action and absence of collateral reactions with the dose used, they recommend its regular use when this investigation is performed.

Total reconstruction of the auricle after traumatic amputation.

We report a technique of auricular replantation used in a case of traumatic amputation. The principal difficulties encountered in this type of replantation are mentioned, and ways of avoiding them are suggested. All the skin of the ear was removed except for that of the anterior surface of the conch. At this site, the cartilage received small, multiple perforations to allow for nutrition of the corresponding skin. The remainder of the auricular cartilage was covered by a skin flap undermined from the mastoid region. Three months later, the retro-auricular region was freed and covered with a total skin graft taken from the right supraclavicular region. On the basis of the satisfactory results obtained, we discuss the intention and the technical details of the method and possible contraindications.

Bacteriology of the anal wound after open hemorrhoidectomy. Qualitative and quantitative analysis.

The purpose of this study is to analyze the size of the bacterial colonies in anal wounds after open hemorrhoidectomy. Twenty patients were studied during predetermined postoperative time periods. Material was collected from the surface and from within the tissue of each patient's three open wounds, intraoperatively, on the 6th, 13th and 20th postoperative days for bacteriologic examination in aerobic, microaerophilic, and anaerobic media. The bacterium most commonly identified was Escherichia coli, followed by Staphylococcus aureus and Staphylococcus epidermidis. Pseudomonas aeruginosa, Enterococcus faecalis, Klebsiella pneumoniae, Proteus vulgaris, and Proteus mirabilis were also identified. Critical indexes of colonization were present since the intraoperative stage (greater than 10(5) bacteria/g of tissue and greater than 10(6) bacteria/ml); obligate anaerobic bacteria were not identified; neither the species nor the number of bacteria, even when critical indexes were present, prevented proper healing. The same bacteria were not necessarily present on the surface and in the tissue; the bacterial load observed among the three wounds (left lateral, right posterior, and right anterior), was the same.

[Pancreatic trauma: analysis of 29 cases]. / Trauma pancreático: análise de 29 casos.

PURPOSE: To investigate the relationship between complications and the kind of pancreatic lesion and surgery performed. KIND OF STUDY: Retrospective. PLACE: The patients were operated on at the Pronto Socorro--Mandaqui Hospital Complex, from January 1987 to January 1990. PATIENTS: The authors analyzed 29 patients victims of penetrating or blunt abdominal trauma who were operated on in that period. 27 of them were male. 20 (69%) were shotgun victims; 5 (17.2%) were victims of cold steels; and 4 (13.8%) were victims of blunt trauma. INTERVENTIONS: In pancreatic head lesions (5 cases), hemostasis and drainage were performed in three cases; duodenopancreatectomy in one case; and suture in one case. In traumas to the pancreatic body (13 cases), six pancreatectomies, five drainages, and two sutures were performed. In traumas to the pancreatic tail (11 cases), six pancreatectomies, four sutures and one drainage were performed. MEASURES AND RESULTS: Complications occurred in all patients with pancreatic head lesions, in eight patients with trauma to the pancreatic body, and in five patients trauma to the pancreatic tail. The most frequent complications were intracavitary abscesses (seven cases), and pancreatic fistulae (five cases). Morbidity rate was 72.4% and mortality rate was 17.2%. CONCLUSION: The authors conclude that indication of pancreatectomy in ductal lesions should be done, exception being made to cases of pancreatic head trauma, for which a suture or simple drainage can be used in superficial lesions. In doubt, an expert surgeon may be called.

Lower eyelid repair utilising triangular skin flaps with subcutaneous pedicles.

Fifty-four patients were studied during the period from 1984 to 1989. The lower eyelid was repaired in 55 cases utilising a triangular flap with a subcutaneous pedicle. Repair was achieved in 39 cases with a triangular flap only and in 16 it was necessary to use a chondromucosal graft of nasal septum as well. The method is described and is feasible for repairs ranging from the simplest to the most complex in different locations of the lid.

Clinical regression of infected pancreatic necrosis. Case report.

Infected pancreatic necrosis was diagnosed clinically and radiologically in a patient admitted for acute pancreatitis. As free gas in the pancreatic area was recognized, antibiotic therapy (ceftriaxone) was empirically introduced, while surgical drainage was being planned. After the second week, the patient rapidly started to improve, to the point that he could be discharged home without operation. Control CT-scans and general laboratory tests, at this phase and later on, confirmed a still enlarged gland but free of infection or ongoing inflammation. Cholelithiasis, which had been identified in an early ultrasound scan, was electively treated by cholecystectomy 2 mo after the onset of pancreatitis, in the absence of sepsis, and with uneventful recovery. This case illustrates the rare possibility of spontaneous regression of infected necrotic pancreatitis, without any type of operation or nonoperative drainage.

[Esophagoplasty with bypass using an isoperistaltic gastric tube in the treatment of cancer of the thoracic esophagus: study of 13 cases]. / Esofagoplastia com tubo gástrico isoperistáltico em derivação no tratamento do câncer do esôfago torácico: estudo de 13 casos.

In order to relieve complete obstruction of the thoracic esophagus due to spinocellular carcinoma, thirteen patients, all of them in good or at least regular general conditions were submitted to a bypass using a isoperistaltic gastric tube. The disease itself was treated by radiotherapy after surgery. Only one patient died at the hospital due to an error in the radiotherapy schedule. Cervical fistula was observed in six patients seven days after surgery; local treatment was enough for complete healing in five out of six. In one patient surgery was performed in order to repair the anastomotic area. Stenosis was observed in three patients but in all cases it was possible to overcome it by endoscopy. With the progress of the disease other complications were observed such as hemoptysis and respiratory distress. The survival rate was nine months (running between five and sixteen) but it should be noted that swallow capacity was maintained until death. The employed of a bypass of isoperistaltic gastric tube seems to be a desirable alternative in the treatment of esophageal cancer because it allows the reestablishment of deglutition before any treatment such as radiotherapy alone or combined with surgery.