Patient-Perceived Barriers to Accessing Cleft Care at a Tertiary Referral Center in São Paulo, Brazil.

BACKGROUND: In low- and middle-income countries, poor access to care can result in delayed surgical repair of orofacial clefts leading to poor functional outcomes. Even in Brazil, an upper middle-income country with free comprehensive cleft care, delayed repair of orofacial clefts commonly occurs. This study aims to assess patient-perceived barriers to cleft care at a referral center in São Paulo. METHODS: A 29-item questionnaire assessing the barriers to care was administered to 101 consecutive patients (or their guardians) undergoing orofacial cleft surgery in the Plastic Surgery Department in Hospital das Clínicas, in São Paulo, Brazil, between February 2016 and January 2017. RESULTS: A total of 54.4% of patients had their first surgery beyond the recommended time frame of 6 months for a cleft lip or cleft lip and palate and 18 months for a cleft palate. There was a greater proportion of isolated cleft palates in the delayed group (66.7% vs 33.3%). Almost all patients had a timely diagnosis, but delays occurred from diagnosis to repair. The mean number of barriers reported for each patient was 3.8. The most frequently cited barriers related to lack of access to care include (1) lack of hospitals available to perform the surgery (54%) and (2) lack of availability of doctors (51%). CONCLUSION: Delays from diagnosis to treatment result in patients receiving delayed primary repairs. The commonest patient-perceived barriers are related to a lack of access to cleft care, which may represent a lack of awareness of available services.

MINIMALLY INVASIVE LAPAROSCOPIC ESOPHAGECTOMY VS. TRANSHIATAL OPEN ESOPHAGECTOMY IN ACHALASIA: A RANDOMIZED STUDY.

BACKGROUND: Open and laparoscopic trans-hiatal esophagectomy has been successfully performed in the treatment of megaesophagus. However, there are no randomized studies to differentiate them in their results. AIM: To compare the results of minimally invasive laparoscopic esophagectomy (EMIL) vs. open trans-hiatal esophagectomy (ETHA) in advanced megaesophagus. METHOD: A total of 30 patients were randomized, 15 of them in each group - EMIL and ETHA. The studied variables were dysphagia score before and after the operation at 24-months follow-up; pain score in the immediate postoperative period and at hospital discharge; complications of the procedure, comparing each group. Were also studied: surgical time in minutes, transfusion of blood products, length of hospital stay, mortality and follow-up time. RESULTS: ETHA group comprised eight men and seven women; in the EMIL group, four women and 11 men. The median age in the ETHA group was 47.2 (29-68) years, and in the EMIL group of 44.13 (20-67) years. Mean follow-up time was 33 months, with one death in each group, both by fatal aspiration. There was no statistically significant difference between the EMIL vs. ETHA scores for dysphagia, pain and in-hospital complications. The same was true for surgical time, transfusion of blood products and hospital stay. CONCLUSION: There was no difference between EMIL and ETHA in all the studied variables, thus allowing them to be considered equivalent.

Minimally invasive laparoscopic esophagectomy vs. transhiatal open esophagectomy in achalasia: a randomized study / Esofagectomia minimamente invasiva laparoscópica vs. esofagectomia trans-hiatal aberta no megaesôfago avançado: estudo randomizado

ABSTRACT Background: Open and laparoscopic trans-hiatal esophagectomy has been successfully performed in the treatment of megaesophagus. However, there are no randomized studies to differentiate them in their results. Aim: To compare the results of minimally invasive laparoscopic esophagectomy (EMIL) vs. open trans-hiatal esophagectomy (ETHA) in advanced megaesophagus. Method: A total of 30 patients were randomized, 15 of them in each group - EMIL and ETHA. The studied variables were dysphagia score before and after the operation at 24-months follow-up; pain score in the immediate postoperative period and at hospital discharge; complications of the procedure, comparing each group. Were also studied: surgical time in minutes, transfusion of blood products, length of hospital stay, mortality and follow-up time. Results: ETHA group comprised eight men and seven women; in the EMIL group, four women and 11 men. The median age in the ETHA group was 47.2 (29-68) years, and in the EMIL group of 44.13 (20-67) years. Mean follow-up time was 33 months, with one death in each group, both by fatal aspiration. There was no statistically significant difference between the EMIL vs. ETHA scores for dysphagia, pain and in-hospital complications. The same was true for surgical time, transfusion of blood products and hospital stay. Conclusion: There was no difference between EMIL and ETHA in all the studied variables, thus allowing them to be considered equivalent.

RESUMO Racional: A esofagectomia trans-hiatal aberta e laparoscópica têm sido realizadas com êxito no tratamento do megaesôfago. Porém, não há estudos randomizados para diferenciá-las em seus resultados. Objetivo: Comparar os resultados da esofagectomia minimamente invasiva laparoscópica (EMIL) vs. esofagectomia trans-hiatal aberta (ETHA) no megaesôfago avançado. Método: Foram randomizados 30 pacientes, sendo alocados 15 em cada grupo - EMIL e ETHA. As variáveis estudadas foram escore de disfagia antes e após a operação no seguimento de 24 meses; escore de dor no pós-operatório imediato e na alta hospitalar; complicações do procedimento, comparando cada grupo. Foram também estudados: tempo cirúrgico em minutos, transfusão de hemoderivados, tempo de permanência hospitalar, mortalidade e tempo de seguimento. Resultados: Foram no grupo ETHA, oito homens e sete mulheres; no grupo EMIL, quatro mulheres e 11 homens. Faixa etária mediana no grupo ETHA foi de 47,2 (29-68) anos, e no grupo EMIL de 44,13 (20-67) anos. Tempo de seguimento médio foi de 33 meses, com um óbito em cada grupo, ambos por aspiração fatal. Não houve diferença estatística significativa, entre os grupos EMIL vs. ETHA quanto aos escores de disfagia, dor e complicações intra-hospitalares. O mesmo se verificou, quanto ao tempo cirúrgico, transfusão de hemoderivados e estadia hospitalar. Conclusão: Não houve diferença entre a EMIL e a ETHA em todas as variáveis estudadas, permitindo assim considerá-las equivalentes.

Medical image retrieval and analysis by Markov random fields and multi-scale fractal dimension.

Many Content-based Image Retrieval (CBIR) systems and image analysis tools employ color, shape and texture (in a combined fashion or not) as attributes, or signatures, to retrieve images from databases or to perform image analysis in general. Among these attributes, texture has turned out to be the most relevant, as it allows the identification of a larger number of images of a different nature. This paper introduces a novel signature which can be used for image analysis and retrieval. It combines texture with complexity extracted from objects within the images. The approach consists of a texture segmentation step, modeled as a Markov Random Field process, followed by the estimation of the complexity of each computed region. The complexity is given by a Multi-scale Fractal Dimension. Experiments have been conducted using an MRI database in both pattern recognition and image retrieval contexts. The results show the accuracy of the proposed method in comparison with other traditional texture descriptors and also indicate how the performance changes as the level of complexity is altered.

Anastomose mecânica esofagogástrica cervical látero-lateral após esofagectomias / Mechanical cervical esophagogastric laterolateral anastomosis after esophagectomies

Dentre os desafios das esofagectomias, a fístula da anastomose cervical persiste desafiadora por suas consequências, sendo a principal, a estenose da anastomose. Os autores apresentam uma técnica de anastomose esofagogástrica cervical látero-lateral mecânica à Orringer, que reduz o índice de fístulas e de estenose.

Among the challenges of esophagectomies, the cervical anastomosis remains challenging for its consequences, the main being the anastomotic stricture. The authors present a technique for an Orringer-fashion mechanical cervical laterolateral esophagogastric anastomosis, which reduces the rate of fistula and stenosis.

Evolutional profile of the esophageal varices after splenectomy associated with ligation of the left gastric vein and sclerotherapy in schistosomal portal hypertension.

BACKGROUND: The schistosomiasis affects 200 million people in 70 countries worldwide. It is estimated that 10% of those infected will develop hepatosplenic status and of these, 30% will progress to portal hypertension and esophagogastric varices, whose expression is through gastrointestinal bleeding with significant mortality in the first bleeding episode. Multiple surgical techniques have been developed to prevent re-bleeding. AIM: To evaluate the evolutional profile of esophageal varices after splenectomy + ligation of the left gastric vein associated with endoscopic sclerotherapy in schistosomal portal hypertension. METHODS: Prospective and observational study including schistosomiasis patients with previous history of upper digestive hemorrhage and underwent to splenectomy + ligation of the left gastric vein and sclerotherapy. The variables were: evolutional profile of esophageal varices before and after surgery and re-bleeding rate. RESULTS: The sample included 30 patients, 15 patients for each gender. The age ranged from 19 to 74 years (median = 43 years). There was a reduction in the degree, caliber and red spots in all patients (p< 0.05). The eradication of varices with sclerotherapy was achieved in 86.7% and with surgery alone in 15.4%. The mean follow-up was 28 months, ranging from two to 76 months. Were carried from one to seven sessions of sclerotherapy and the average was three per patient to eradicate varices. Four (13.3%) did not complete the follow-up. The re-bleeding rate was 16.7%. CONCLUSION: There was a reduction of the degree, caliber and red spots of esophageal varices in all patients.

Perfil evolutivo das varizes esofágicas pós esplenectomia associada à ligadura da veia gástrica esquerda e escleroterapia na hipertensão portal esquistossomótica / Evolutional profile of the esophageal varices after splenectomy associated with ligation of the left gastric vein and sclerotherapy in schistosomal portal hypertension

RACIONAL: A esquistossomose mansônica afeta 200 milhões de pessoas em 70 países do mundo. Estima-se que 10% dos infectados evoluirão para a forma hepatoesplênica e, destes, 30% progredirão para hipertensão portal e varizes esofagogástricas, cuja expressão será através de hemorragia digestiva com mortalidade relevante no primeiro episódio hemorrágico. Múltiplas técnicas cirúrgicas foram desenvolvidas para prevenir o ressangramento. OBJETIVO: Avaliar o perfil evolutivo das varizes esofágicas após esplenectomia + ligadura da veia gástrica esquerda associada à escleroterapia endoscópica na hipertensão portal esquistossomótica. MÉTODO: Estudo prospectivo, observacional, de pacientes esquistossomóticos com antecedentes de hemorragia digestiva alta, submetidos à esplenectomia + ligadura da veia gástrica esquerda e escleroterapia. As variáveis estudadas foram perfil evolutivo das varizes esofágicas antes e após a operação e índice de recidiva hemorrágica. RESULTADOS: Amostra foi constituída por 30 pacientes distribuídos, quanto ao gênero, em 15 doentes para cada sexo. A idade variou de 19 a 74 anos (mediana=43 anos). Houve redução do grau, calibre e red spots em todos os pacientes (p<0,05). A erradicação das varizes com escleroterapia foi alcançada em 86,7% e exclusivamente com a operação em 15,4% dos pacientes.O tempo de seguimento médio foi de 28 meses, variando de dois a 76 meses. Foram realizadas de uma a sete sessões de escleroterapia e média de três por paciente para erradicar as varizes. Quatro pacientes (13,3%) não completaram o seguimento. A recidiva hemorrágica foi de 16,7%. CONCLUSÃO: Houve redução do grau, calibre e dos red spots das varizes esofágicas em todos os pacientes.

BACKGROUND: The schistosomiasis affects 200 million people in 70 countries worldwide. It is estimated that 10% of those infected will develop hepatosplenic status and of these, 30% will progress to portal hypertension and esophagogastric varices, whose expression is through gastrointestinal bleeding with significant mortality in the first bleeding episode. Multiple surgical techniques have been developed to prevent re-bleeding. AIM: To evaluate the evolutional profile of esophageal varices after splenectomy + ligation of the left gastric vein associated with endoscopic sclerotherapy in schistosomal portal hypertension. METHODS: Prospective and observational study including schistosomiasis patients with previous history of upper digestive hemorrhage and underwent to splenectomy + ligation of the left gastric vein and sclerotherapy. The variables were: evolutional profile of esophageal varices before and after surgery and re-bleeding rate. RESULTS: The sample included 30 patients, 15 patients for each gender. The age ranged from 19 to 74 years (median = 43 years). There was a reduction in the degree, caliber and red spots in all patients (p< 0.05). The eradication of varices with sclerotherapy was achieved in 86.7% and with surgery alone in 15.4%. The mean follow-up was 28 months, ranging from two to 76 months. Were carried from one to seven sessions of sclerotherapy and the average was three per patient to eradicate varices. Four (13.3%) did not complete the follow-up. The re-bleeding rate was 16.7%. CONCLUSION: There was a reduction of the degree, caliber and red spots of esophageal varices in all patients.

Mechanical cervical esophagogastric laterolateral anastomosis after esophagectomies.

Among the challenges of esophagectomies, the cervical anastomosis remains challenging for its consequences, the main being the anastomotic stricture. The authors present a technique for an Orringer-fashion mechanical cervical laterolateral esophagogastric anastomosis, which reduces the rate of fistula and stenosis.

Marcadores de prognóstico no abscesso hepático piogênico / Pyogenic liver abscess: analysis of prognostic factors

Objetivo:Analisar os marcadores de prognóstico no abscesso hepático piogênico. Casuística e método: Foram estudados retrospectivamente 26 pacientes admitidos na Unidade de Emergência Armando Lages-Maceió e no Hospital Universitário Prof. Alberto Antunes, da Universidade Federal de Alagoas, com diagnóstico de abscesso hepático piogênico confirmado à laparotomia exploradora, período 1993-99. Foram estudadas as seguintes variáveis: idade, sexo, icterícia, número de abscessos, localização, choque, rotura, diâmetro, hematócrito e número de leucócitos. A análise estatística foi feita pelos testes de Fisher e Mann-Whitney, sendo considerados significantes respectivamente os valores de p<0,01 e p<0,05. Métodos: Dezenove pacientes eram do sexo masculino e sete do feminino. A idade média foi de 31 anos e variou de três a 92 anos. Resultados: as manifestações clínicas principais foram dor abdominal e febre. O abscesso com lesão única no lobo direito foi a apresentação mais frequente. A drenagem cirúrgica com antimicrobianos foi a terapêutica predominante e a mortalidade global doi de 26,9por cento. Os marcadores idade, sexo, número de abscessos, localização, hematócrito e o número de leucócitos não foram significantes, icterícia, rotura, choque séptico e o diâmetro do abscesso foram os marcadores de prognóstico significantes para mortalidade. Conclusão: Os marcadores de prognóstico para evolução desfavorável foram: presença de icterícia, choque séptico, rotura e o diâmetro do abscesso

Esofagectomia trans-hiatal no tratamento do megaesôfago chagásico avançado / Transhiatal esophagectomy for chagas's disease megaesophagus

OBJETIVO: Avaliar os resultados da esofagectomia trans-hiatal no tratamento do megaesôfago chagásico avançado. MÉTODO: Foram estudados retrospectivamente 28 pacientes portadores de megaesôfago chagásico avançado (MCA), graus III e IV, segundo a classificação radiológica de Rezende (adotada pela Organização Mundial de Saúde), e que foram submetidos à esofagectomia subtotal trans-hiatal no Serviço de Clínica Cirúrgica do Hospital Universitário Prof. Alberto Antunes (HUPAA) da Universidade Federal de Alagoas, entre 1982 e 2000. Foram analisadas, as seguintes variáveis: A) Queixas clínicas pré-operatórias versus as pós-operatórias (disfagia, regurgitação, pirose, diarréia, dumping, plenitude pós-prandial, pneumonia e o estado ponderal). B) avaliação radiológica pós-operatória da boca anastomótica esofagogástrica cervical e do estômago transposto. C) avaliação endoscópica pós-operatória do coto esofágico e da boca anastomótica. RESULTADOS: O seguimento variou de 4 a 192 meses, média de 58,18 meses. Dezesseis pacientes eram do sexo feminino e 12 masculinos. Idade mínima de 16 e máxima de 67 anos, média de 36,5 anos. Não houve mortalidade nesta série. Houve resolução plena da disfagia na maioria dos pacientes (20/28 - 71,4 por cento), um (3,6 por cento) referiu disfagia leve que não necessitou tratamento e 7/28 (25 por cento) necessitaram de uma ou mais sessões de dilatação. Nenhum necessitou de dilatação permanente. A pirose foi o sintoma mais importante no seguimento tardio (35,7 por cento), seguida da regurgitação (25 por cento), diarréia (14,3 por cento), plenitude pós-prandial (10,7 por cento) e dumping (3,6 por cento). Houve ganho ponderal em 87,5 por cento dos pacientes avaliados. A esofagite no coto esofágico foi o achado endoscópico mais significativo (46,4 por cento). O esôfago de Barrett no coto remanescente foi encontrada em 10,7 por cento dos casos. A maioria dos achados radiológicos foi normal, embora três doentes (10,7 por cento)...

BACKGROUND: To analize the clinical results, radiologic and endoscopic findings of the transhiatal esophagectomy on Chaga's disease megaesophagus. METHODS: A retrospective study was performed from 1982-2000. Twenty-eight chagasic patients, sixteen female and twelve male, were treated at the General Surgery Service of Hospital da Universidade Federal de Alagoas. The disease was diagnosed by serologic trials and epidemiological or anatomopathological information. Variables studied were: a) pre and postoperative surgery patients complaints as dysphagia, regurgitation, pyrosis, diarrhea, dumping, postprandial fullness, pneumonia and weight status; b) post surgery X Rays series (upper GI) evaluation of the cervical esophagogastric anastomosis and the transposed stomach; c) post surgery endoscopic evaluation to analyze the esophagus stump and the anastomotic suture. The follow-up quantitative variable was expressed by medium and error pattern. The Chi-square test was applied to the dysphagia, regurgitation and pyrosis resolution variables considering p<0,05 values significant. The qualitative variables by percentage and the trusting interval calculated within 95 percent (IC-95 percent), with the EpiInfo software. RESULTS: Mean follow-up was 58,2 months (from to 4 - 192). Mean age was 36,5 years (from to 16-67). There was no mortality in this series. There was complete resolution of dysphagia in the majority of the patients (21/28 - 71,4 percent, p<0,05); 7/28 (25 percent) needed one or more dilatation sessions. Pyrosis was the most important late follow-up symptom (35,7 percent) and stump esophagitis the most significant endoscopic finding. The majority of X Rays studies findings were normal. CONCLUSIONS: Transhiatal esophagectomy was efficient to the treatment of chagasic megaesophagus dysphagia however the morbidity was high (78,6 percent). The mortality in this series was none.

Abscesso hepático piogênico associado à esquistossomose mansônica / Liver piogenic abscess associated to schistosomiasis

The authors report a case of the 15 year old young man, from endemic zone of schistosomiasis and with a chronic schistosomiasis, was admitted complaining of continuous pain in the right upper quadrant, spreaded to epigastrium and right lower quadrant which, began 10 days before. It was associated to fever, anorexia, hepatomegaly, esplenomegaly and signs of peritoneal irritation without clinical improvement. At laparotomy multiple liver microabscesses were found. Excluded the classic etiology, a liver biopsy was done and showed Schistossoma mansoni eggs, surrounded by the same inflamatory cells of microabscesses. This suggested that they have been the predisposing cause for the formation of liver abscesses, as shown in the literature. Schistosomiasis can be complicated with pylephlebitis, immunodepression and granulomatous reaction, central lobular necrosis and a raise in the infection risk. The described data suggest the schistosomiasis as the etiology of hepatic microabscesses, mainly in endemic zones

Tratamento dos cálculos residuais do coledoco com heparina / Treatment of residual choledochal stones with heparin

Os autores relatam dois casos de calculos residuais no coledoco tratados com exito com solucao fisiologica heparinizada (50.000u de heparina em cada 500 ml de soro fisiologico isotonico - 3x/dia, por periodo de seis horas. O metodo e simples e nao ha alteracoes na coagulacao. Sugerem ser uma opcao de tratamento para os cirurgioes que nao tem acesso a terapeutica endoscopica contemporanea.

Hepatocarcinoma: estudo de 4 casos / Hepatocarcinoma: 4 cases studied

Analisamos quatro casos de hepatocarcinoma em 13 anos, no Hospital Universitario da Universidade Federal de Alagoas. O tempo do aparecimento do 1 sintoma a procura de auxilio medico variou de 2 a 7 meses, com media de 4 meses. As queixas iniciais mais comuns foram: dor abdominal e emagreciment(100%); tumoraçao abdominal (75%). Ao exame fisico todos pacientes tinham hepatomegalia.. Houve antecedentes de transfusao de sangue, esquistossomose, portador cronico de virus da hepatite B, alcoolismo e uso denanticonceptivos orais.O diagnostico definitivo foi feito em 50% dos casos pela biopsia laparoscopica;25% por laparotomia exploradora e biopsia; e 25% por biopsia transparietohepatica.Em face do estagio adiantado em que se apresentaram, em todos os casos, nao foi instituido tratamento adequado. Concluimos portanto, a necessidade de se desenvolver meios para diagnostico precoce dessa patologia, em nosso meio

Reoperações em cirurgia abdominal de urgência / Reoperations in abdominal emergency

Analisamos 177.244 laparotomias na literatura - incluida nossa série de 905 - , em que 3.051 pacientes (1.7%), foram relaparotomizados e destes 1.331 (44%) foram a óbito. Realizamos 69 reoperações em 53 pacientes (5.8%) dentre 905 laparotomias de urgência, com mortalidade de 43.3%, sendo 33 masculinos e 20 femininos. Idade média. de 29,7 anos. O mais jovem tinha um ano de idade e o mais idoso 75 anos. Dezessete deles tinham sido operados primariamente por três cirurgiões que vivenciaram esta experiência; com mortalidade de 47% e incidência de 1.95% de reoperações. Sepsis ou abdomen agudo inflamatório associou-se I aos óbitos em 86.9% e fatores iatrogênicos em 13 pacientes dos reoperados. Peritonite difusa na laparotomia inicial, número de reintervenções e a etiologia interferem na evolução de forma estatisticamente significante. Enfim, discutimos nossa experiência cotejando a literatura.