Late results on the surgical treatment of Chagasic megaesophagus with the Thal-Hatafuku procedure.

BACKGROUND: Chagas' disease has a wide distribution in Central and South America. It is endemic in 21 countries, with 16 to 18 million persons infected and 100 million at risk. Surgical treatment of achalasia from Chagas' disease is the first choice in advanced stages. The aim of this study was to analyze the late clinical followup of 50 patients operated on for Chagas megaesophagus with the Thal-Harafuku procedure. STUDY DESIGN: During the period of January 1966 to January 1993, 50 patients suffering from advanced achalasia from Chagas' disease were submitted to the Thal-Hatafuku procedure. The patients answered a questionnaire concerning the most relevant postoperative symptoms. The Thal-Hatafuku procedure was performed as the first surgical option (46 patients), and on reoperations because of failure of other surgical techniques (4 patients). RESULTS: The mean followup was 63.11 months for the 44 patients with longterm followup. Postoperative complications included surgical site infection (3 of 50 patients), urinary infections (3 of 50 patients), atelectasis (2 of 50 patients), pleural effusion (2 of 50 patients), and deep venous thrombosis (1 of 50 patients). The main symptoms found in the postoperative period were dysphagia (20 of 44 patients), heartburn (11 of 44 patients), vomiting (13 of 44 patients), and retrosternal pain (6 of 44 patients). Eleven patients of the 44 remained asymptomatic at the end of the followup period. Outcomes were analyzed according to the modified Visick classification. Visick classes I and II represented 25% and 27.3%, respectively. Eighteen patients (40.9%) were classified as Visick III. CONCLUSION: We conclude that the Thal-Hatafuku operation is a therapeutic option that should be considered in the treatment of achalasia of the esophagus secondary to Chagas' disease, in advanced cases.

Surgical treatment of schistosomal portal hypertension.

Schistosomiasis mansoni is a widespread parasitic disease in the Brazilian territory that affects over 8 million individuals. Hepatosplenic schistosomiasis is a serious clinical presentation of this disease, associated with splenomegaly, liver fibrosis, and portal hypertension, and is responsible for approximately 7% of schistosomotic patients. The surgical treatment of portal hypertension in schistosomotic patients has distinct features when compared with cirrhotic patients, mostly because hepatic function is preserved in schistosomotic liver disease. Therefore, when attempting to reduce the portal pressure, the surgeon must be aware that the surgery might interfere with hepatic perfusion, and consequently with hepatic function. The aim of this study was to report the results achieved with splenectomy, division of the left gastric vein, devascularization of great gastric curvature, and postoperative endoscopic variceal sclerosis, as a surgical option to esophageal varices in hepatosplenic schistosomiasis. A total of 111 patients were studied, and the following is a list of inclusion criteria: age >16 years, history of gastrointestinal (GI) bleeding, presence of esophageal varices on preoperative endoscopy, hematocrit >22% and prothrombin enzymatic activity >50%, negative viral hepatitis on serologic tests (anti-HBV and anti-HCV), and definition, after liver biopsy, of exclusive schistosomotic liver disease. The following list includes exclusion criteria used: presence of liver disease other than schistosomotic, history of alcohol abuse, and preoperative thrombosis of the portal vein. The rebleeding rate was 14.4% during a mean 30-month follow-up period; portal vein thrombosis was 13.2%, and there was a global mortality of 5.4%. Gastric varices were present in 46.9% of the patients; for those patients, a gastrotomy and running suture of the varices achieved an eradication rate of the varices of 75.6%. The degree of periportal fibrosis was also analyzed. Periportal fibrosis staging revealed that patients with class II or III liver fibrosis had a significant increased risk of recurrent GI bleeding when compared with patients with class I liver fibrosis. Despite the elevation on alanine aminotransferase (ALT) and aspartate aminotransferase (AST), most other liver function tests showed no alteration or were corrected after surgery. We conclude that splenectomy, division of the left gastric vein, devascularization of great gastric curvature, and postoperative endoscopic variceal sclerosis showed good results globally and should be considered as therapeutic options in the treatment of hepatosplenic schistosomiasis.

Postdischarge surveillance for nosocomial wound infection: does judicious monitoring find cases?

From 1988 through 1992, we conducted a prospective study of postdischarge surgical wound infection surveillance in our institution. A total of 6604 patients were seen after discharge in a centralized outpatient clinic, supervised by the infection control commission. Wounds were inspected, stitches were removed, and dressings were changed. This care was followed by referral of patients to the appropriate specialized surgical clinic. Postdischarge patient return rates for the period studied ranged from 68.4% to 91.2%. Wound infection detection in the outpatient clinic ranged from 32.2% (20 patients in 1991) to 50% (44 patients in 1990) for general surgical procedures and 52.9% (18 patients in 1990) to 91.4% (32 patients in 1992) for cesarean sections. Most surgical wound infections (87.6%, 127 patients) were diagnosed between the first and fourteenth postoperative days. We conclude that centralized postdischarge surveillance, as practiced in our institution, has enhanced the retrieval of wound infection data. At present, there is no universally accepted strategy for monitoring postdischarge surgical wound infection; however, we must take a rigorous approach to detect patients at risk for infection in our continuous attempt to improve the quality of surgical and postoperative care.

Wound infection rates in clean surgery: a potentially misleading risk classification.

OBJECTIVES: To evaluate the incidence of wound infection in inguinal hernioplasties, incisional hernioplasties, splenectomies, and splenectomies performed in patients with hepatosplenic schistosomiasis, and to examine the relationship of surgical wound infection to antibiotic use, patient age, length of stay in the hospital prior to surgery, and the duration of the operation. DESIGN: Retrospective surveillance study. RESULTS: One thousand five hundred forty-two clean operations were analyzed. Comparing response (wound infection) and explanatory variables (age, length of hospital stay, duration of surgery, antibiotics, and surgery type), we found that age, use of antibiotics, and type of surgery were statistically significant, while length of hospital stay and duration of surgery were not significant. CONCLUSIONS: From these results, we can predict that the probability of wound infection in surgical patients considering these significant variables is lower for patients ages 14 to 30 years and higher for patients ages 31 to 60 years and lower for patients with prophylactic antibiotic use (up to 72 hours of use) and higher for patients with prolonged use (more than 72 hours); and lower for patients undergoing inguinal heria, followed in ascending order by nonschistosomotic patients undergoing splenectomy in schistosomotic patients.

Regeneracao hepatica pos-hepatectomia parcial em ratos com fibrose esquistossomotica. / Hepatic regeneration after partial hepatectomy in rats with schistosomotic fibrosis

A regeneracao hepatica pos-hepatectomia parcial em ratos albinos com fibrose esquistossomotica foi estudada atraves da contagem de figuras de mitose, hepatocitos binucleados e cariometria dos hepatocitos em 39 ratos albinos distribuidos em dois grupos: A - 23 ratos dois machos e duas femeas infectados no 3o. mes, e submetidos a hepatectomia parcial no 13o. mes e avaliada a regeneracao 48 horas apos a hepatectomia parcial; B - 16 ratos sete machos e nove femeas sem infeccao operados e avaliada a regeneracao nas mesmas condicoes do grupo A. Os resultados obtidos mostram com uma confianca de 5% que ocorreu regeneracao hepatico pos-hepatectomia parcial de ratos com fibrose hepatica esquistossomotica de forma semelhante aos ratos normais

Advanced megaesophagus with recurrent dysphagia following initial surgical treatment.

The results of the surgical treatment of twenty patients with advanced megaesophagus who had undergone previous treatment are presented. After the previous operation, the asymptomatic period was less than five years in mot cases; symptoms included dysphagia (100%), regurgitation (65%), heartburn (50%), pain (45%), excess saliva (20%) and palpitations (10%). The definitive treatment was cervico-abdominal esophagectomy (45%), distal esophagectomy (20%), Thal-Hatafuku's operation (15%) and miscellaneous (15%). In our experience, the best procedures are cervico-abdominal esophagectomy and Thal-Hatafuku's operation.

Ascorbic acid in schistosomiasis mansoni with or without digestive haemorrhage.

The authors studied the variations of ascorbic acid levels in white blood cells and plasma by Denson-Bowers' method in 20 normal individuals (Group I) and 36 schistosoma patients with hepatosplenic disease with and without gastrointestinal haemorrhage (Groups II and III, including 18 patients each). Having submitted the results to statistical analysis with a probability rate of 95%, the authors concluded that, while no significant difference could be seen between Groups I, II and III in ascorbic acid levels in white blood cells, there was a significant decrease in plasma ascorbic acid levels of Group III as compared with Groups I and II.

Acido ascorbico na esquistossomose mansonica na vigencia ou nao de episodio de hemorragia digestiva. / Ascorbic acid in schistosomiasis mansoni with and without gastrointestinal haemorrhage

Estudo das variacoes dos niveis leucocitarios e plasmaticos de acido ascorbico, pelo metodo de Denson e Bowers, em 20 individuos normais (Grupo I) e em 36 pacientes esquistossomoticos na forma hapato-esplenica sem e com hemorragia digestiva (Grupos II e III, com 18 pacientes cada). Os resultados foram submetidos a uma analise estatistica (t de student) com uma probabilidade de confianca de 95%.Obteve resultados que nao demonstraram diferenca significativa entre os valores do acido ascorbico nos leucocitos dos Grupos I, II e III e observou uma diminuicao significante das concentracoes plasmaticas deste acido no Grupo III, quando comparadas com as dos Grupos I e II

Regeneracao hepatica pos-hepatectomia parcial em ratos com fibrose esquistossomotica, antes e apos o tratamento medicamentoso. / Liver regeneration after partial hepatectomy in rats with schistosomotic fibrosis, before and after drug therapy

A regeneracao hepatica pos-hepatectomia parcial em ratos albinos com fibrose esquistossomotica apos o tratamento medicamentoso da esquistossomose, estudada atraves da cariometria dos hepatocitos e contagem de figuras de mitose e hepatocitos binucleados em 45 ratos albinos distribuidos em dois grupos: Grupo A: 29 ratos, 15 machos e 14 femeas, infectados no 3o mes de vida com uma carga de 400 cercarias de S. mansoni por animal e tratados com uma dose unica de 15 mg/kg de hycanthone por via intraperitoneal, seis meses apos a infeccao e submetidos a hepatectomia parcial no 13o mes de vida e avaliada a regeneracao hepatica 48 horas apos a hepatectomia; Grupo B: 16 ratos, 10 machos e seis femeas, sem infeccao, que receberam hycanthone em dose unica de 15 mg/kg por via intraperitoneal no 9o mes de vida e quatro meses apos foram submetidos a hepatectomia parcial, sendo os sobreviventes sacrificados 48 horas apos a intervencao. Os resultados obtidos mostram com uma confianca de 5o que ocorreu regeneracao hepatica poshepatectomia parcial em ratos com fibrose esquistossomotica, apos o tratamento medicamentoso, de forma semelhante aos animais normais com relacao aos parametros cariometria dos hepatocitos binucleados

Proximal gastric vagotomy in stenosed or perforated duodenal ulcer.

Thirty-five patients suffering from stenosed or perforated duodenal ulcer, who were submitted to surgical treatment in the form of proximal gastric vagotomy, are presented. There were no deaths in the series and the results were considered to be very good in the cases of perforation, whereas a high incidence of poor results (27 per cent) occurred in the cases of stenosis submitted to a proximal gastric vagotomy combined with digital dilatation of the pylorus.

Concentracoes leucocitarias e plasmaticas do acido ascorbico em portadores da forma hepatoesplenica da esquistossomose mansonica. / Ascorbic acid levels in white blood cells and plasma of patients with hepatosplenic form of schistosomiasis

Estudo das concentracoes leucocitarias e plasmaticas do acido ascorbico, pelo metodo de Denson e Bowers em 18 pacientes esquistossomoticos na forma hepatoesplenica (Grupo I) e em 20 individuos normais (Grupo II) que constituiram o Grupo-Controle. Os resultados foram submetidos a uma analise estatistica (t de Student) com uma probabilidade de confianca de 95%. Observou que nao houve diferenca estatisticamente significante entre os niveis do acido ascorbico nos leucocitos e no plasma dos grupos I e II

A vagotomia gastrica proximal no tratamento cirurgico da ulcera duodenal estenosada e perfurada. / Proximal gastric vagotomy in the surgical treatment of stenosing and perforating duodenal ulcer

Os autores apresentam um material de 35 pacientes portadores de ulcera duodenal estenosada e perfurada, submetidos a tratamento cirurgico utilizado a vagotomia gastrica proximal. Nao houve mortalidade na serie e os resultados foram considerados muito bons nos casos de perfuracao, ocorrendo elevado indice de maus resultados (27,27) nos casos de estenose submetidos a uma vagotomia gastrica proximal associada a dilatacao digital do pilor

Tratamento cirurgico do megaesofago chagasico. Avaliacao de 60 casos. / Surgical treatment of chagasic megaesophagus

Os autores estudaram retrospectivamente o resultado do tratamento cirurgico de 60 pacientes portadores de megaesofago, sendo 22 submetidos a operacao de Heller associada a um procedimento antirefluxo, 22 a operacao de Thal Hatafuku e 16 a esofogectomia cervico-abdominal (Op. Eugenio Ferreira).O seguimento pos-operatorio global foi de 73,33% e ocorreram dois casos de obito entre os submetidos a operacao de Thal Hatafuku (4,54%). Os resultados considerados bons e regulares ocorreram em 59,11% dos casos submetidos a operacao de Heller associada a um procedimento antirefluxo, 40,92% apos a operacao de Thal Hatafuku e 87,50% apos a operacao de Eugenio Ferreira