ALTERNATIVE FISTULA RISK SCORE AND FIRST POSTOPERATIVE DAY DRAIN FLUID AMYLASE AS PREDICTORS OF PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY.

BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

Alternative fistula risk score and first postoperative day drain fluid amylase as predictors of pancreatic fistula after pancreaticoduodenectomy / Escore alternativo de risco de fístula e níveis de amilase do fluido de drenagem no primeiro dia de pós-operatório como preditores de fístula pancreática após pancreaticoduodenectomia

ABSTRACT BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

RESUMO RACIONAL: A alta morbimortalidade da pancreaticoduodenectomia está associada, principalmente, à anastomose pancreatojejunal, a mais frágil e suscetível a complicações como a fístula pancreática pós-operatória clinicamente relevante (clinically relevant postoperative pancreatic fistula - CR-POPF). OBJETIVOS: O escore alternativo de risco de fístula (alternative fistula risk score) e os níveis de amilase do fluido de drenagem no primeiro dia pós-operatório (first postoperative day drain fluid) são preditores da ocorrência de fístula pancreática pós-operatória clinicamente relevante. Nenhum consenso foi alcançado sobre qual das pontuações é um melhor preditor; além disso, seu poder preditivo combinado permanece obscuro. Até onde sabemos, essa associação ainda não havia sido estudada. MÉTODOS: Este estudo avaliou o efeito preditivo do escore alternativo de risco de fístula e/ou do fluido de drenagem no primeiro dia pós-operatório em uma coorte retrospectiva de 58 pacientes após pancreaticoduodenectomia. Os testes de Shapiro-Wilk e Mann-Whitney foram aplicados para avaliar a distribuição das amostras e para comparar as medianas, respectivamente. A curva de características operacionais do receptor e a matriz de confusão foram utilizadas para analisar os modelos preditivos. RESULTADOS: Os valores do escore alternativo de risco de fístula não foram estatisticamente diferentes entre os pacientes dos grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 59,5, p=0,12). Os valores de fluido de drenagem no primeiro dia pós-operatório foram estatisticamente diferentes entre os grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 27, p=0,004). O escore alternativo de risco de fístula e fluido de drenagem no primeiro dia pós-operatório foram independentemente menos preditivos para fístula pancreática pós-operatória clinicamente relevante, em comparação com escore alternativo de risco de fístula + fluido de drenagem no primeiro dia pós-operatório combinados. CONCLUSÕES: O modelo combinado envolvendo escore alternativo de risco de fístula>20% + fluido de drenagem no primeiro dia pós-operatório=5.000 U/L foi o preditor mais eficaz da ocorrência de fístula pancreática pós-operatória clinicamente relevante após pancreaticoduodenectomia.

Quantitative Aspects of Diffusion-weighted Magnetic Resonance Imaging in Rectal Cancer Response to Neoadjuvant Therapy.

BACKGROUND: The aim of the study was to evaluate the added value of the apparent diffusion coefficient (ADC) of diffusion-weighted magnetic resonance imaging (DW-MRI) in patients with rectal cancer who received neoadjuvant chemoradiotherapy (CRT). The use of DW-MRI for response evaluation in rectal cancer still remains a widely investigated issue, as the accurate detection of pathologic complete response (pCR) is critical in making therapeutic decisions. PATIENTS AND METHODS: Thirty-three patients with locally advanced rectal cancer were evaluated retrospectively by MRI in addition to diffusion-weighted images (DWI) and its ADC pre- and post-neoadjuvant CRT. These patients subsequently underwent curative-intent surgery. Tumor staging by MRI and ADC value were compared with histopathological findings of the surgical specimen. RESULTS: MRI in addition to DWI had a sensitivity of 96.1%, specificity of 71.4%, positive predictive value of 92.5%, and negative predictive value of 83.3% in the detection of pCR. The pre-CRT ADC alone could not reliably predict the pCR group. Post-CRT ADC cutoff value of 1.49 x 10-3 mm2/s had the highest accuracy and allowed a 16.7% increase in negative predictive value and 3.9% increase in sensitivity. Patients with pCR to neoadjuvant treatment differed from the other groups in their absolute values of post-CRT ADC (p < 0.01). CONCLUSIONS: The use of post-CRT ADC increased the diagnostic performance of MRI in addition to DWI in predicting the final pathologic staging of rectal carcinoma.

The destruction complex of beta-catenin in colorectal carcinoma and colonic adenoma.

OBJECTIVE: To evaluate the destruction complex of beta-catenin by the expression of the proteins beta-catetenin, adenomatous polyposis coli, GSK3ß, axin and ubiquitin in colorectal carcinoma and colonic adenoma. METHODS: Tissue samples from 64 patients with colorectal carcinoma and 53 patients with colonic adenoma were analyzed. Tissue microarray blocks and slides were prepared and subjected to immunohistochemistry with polyclonal antibodies in carcinoma, adjacent non-neoplastic mucosa, and adenoma tissues. The immunoreactivity was evaluated by the percentage of positive stained cells and by the intensity assessed through of the stained grade of proteins in the cytoplasm and nucleus of cells. In the statistical analysis, the Spearman correlation coefficient, Student's t, χ2, Mann-Whitney, and McNemar tests, and univariate logistic regression analysis were used. RESULTS: In colorectal carcinoma, the expressions of beta-catenin and adenomatous polyposis coli proteins were significantly higher than in colonic adenomas (p<0.001 and p<0.0001, respectively). The immunoreactivity of GSK3ß, axin 1 and ubiquitin proteins was significantly higher (p=0.03, p=0.039 and p=0.03, respectively) in colorectal carcinoma than in the colonic adenoma and adjacent non-neoplastic mucosa. The immunohistochemistry staining of these proteins did not show significant differences with the clinical and pathological characteristics of colorectal cancer and colonic adenoma. CONCLUSIONS: These results suggest that, in adenomas, the lower expression of the beta-catenin, axin 1 and GSK3ß proteins indicated that the destruction complex of beta-catenin was maintained, while in colorectal carcinoma, the increased expression of beta-catenin, GSK3ß, axin 1, and ubiquitin proteins indicated that the destruction complex of beta-catenin was disrupted. OBJETIVO: Avaliar o complexo de destruição da betacatenina no carcinoma colorretal e no adenoma do colo pela expressão das proteínas betacatenina, adenomatous polyposis coli, GSK3ß, axina e ubiquitina. MÉTODOS: Amostras de tecidos de 64 doentes com carcinoma colorretal e de 53 pacientes com adenoma do colo foram analisadas. Blocos de tecidos foram submetidos ao estudo imuno-histoquímico com anticorpos policlonais nos tecidos do carcinoma, mucosa não neoplásica adjacente e adenoma. A imunorreatividade foi avaliada pela porcentagem de positividade de células coradas e pela intensidade do grau de coloração das proteínas no citoplasma e no núcleo das células. Na análise estatística, foram utilizados o coeficiente de correlação de Spearman, os testes t de Student, χ2, Mann-Whitney e de McNemar, e a análise de regressão logística univariada. RESULTADOS: No carcinoma colorretal, as expressões da betacatenina e da adenomatous polyposis coli foram significativamente maiores do que em adenomas do colo (p<0,001 e p<0,0001, respectivamente). A imunorreatividade das proteínas GSK3ß, axina 1 e ubiquitina foi significativamente maior (p=0,03, p=0,039 e p=0,03, respectivamente) no carcinoma colorretal do que no adenoma e na mucosa não neoplásica adjacente. A coloração imuno-histoquímica dessas proteínas não apresentou diferenças significantes em relação às características clinicopatológicas do câncer colorretal e do adenoma. CONCLUSÕES: Em adenomas, as menores expressões de betacatenina, axina 1 e GSK3ß indicaram que o complexo de destruição da betacatenina estava conservado, enquanto que, no carcinoma colorretal, o aumento das expressões da betacatenina, GSK3ß, 1 axina, e ubiquitina indicaram que o complexo de destruição de betacatenina estava alterado.

The destruction complex of beta-catenin in colorectal carcinoma and colonic adenoma / O complexo destruidor de betacatenina no carcinoma colorretal e no adenoma cólico

ABSTRACT Objective To evaluate the destruction complex of beta-catenin by the expression of the proteins beta-catetenin, adenomatous polyposis coli, GSK3β, axin and ubiquitin in colorectal carcinoma and colonic adenoma. Methods Tissue samples from 64 patients with colorectal carcinoma and 53 patients with colonic adenoma were analyzed. Tissue microarray blocks and slides were prepared and subjected to immunohistochemistry with polyclonal antibodies in carcinoma, adjacent non-neoplastic mucosa, and adenoma tissues. The immunoreactivity was evaluated by the percentage of positive stained cells and by the intensity assessed through of the stained grade of proteins in the cytoplasm and nucleus of cells. In the statistical analysis, the Spearman correlation coefficient, Student’s t, χ2, Mann-Whitney, and McNemar tests, and univariate logistic regression analysis were used. Results In colorectal carcinoma, the expressions of beta-catenin and adenomatous polyposis coli proteins were significantly higher than in colonic adenomas (p<0.001 and p<0.0001, respectively). The immunoreactivity of GSK3β, axin 1 and ubiquitin proteins was significantly higher (p=0.03, p=0.039 and p=0.03, respectively) in colorectal carcinoma than in the colonic adenoma and adjacent non-neoplastic mucosa. The immunohistochemistry staining of these proteins did not show significant differences with the clinical and pathological characteristics of colorectal cancer and colonic adenoma. Conclusions These results suggest that, in adenomas, the lower expression of the beta-catenin, axin 1 and GSK3β proteins indicated that the destruction complex of beta-catenin was maintained, while in colorectal carcinoma, the increased expression of beta-catenin, GSK3β, axin 1, and ubiquitin proteins indicated that the destruction complex of beta-catenin was disrupted.

RESUMO Objetivo Avaliar o complexo de destruição da betacatenina no carcinoma colorretal e no adenoma do colo pela expressão das proteínas betacatenina, adenomatous polyposis coli, GSK3β, axina e ubiquitina. Métodos Amostras de tecidos de 64 doentes com carcinoma colorretal e de 53 pacientes com adenoma do colo foram analisadas. Blocos de tecidos foram submetidos ao estudo imuno-histoquímico com anticorpos policlonais nos tecidos do carcinoma, mucosa não neoplásica adjacente e adenoma. A imunorreatividade foi avaliada pela porcentagem de positividade de células coradas e pela intensidade do grau de coloração das proteínas no citoplasma e no núcleo das células. Na análise estatística, foram utilizados o coeficiente de correlação de Spearman, os testes t de Student, χ2, Mann-Whitney e de McNemar, e a análise de regressão logística univariada. Resultados No carcinoma colorretal, as expressões da betacatenina e da adenomatous polyposis coli foram significativamente maiores do que em adenomas do colo (p<0,001 e p<0,0001, respectivamente). A imunorreatividade das proteínas GSK3β, axina 1 e ubiquitina foi significativamente maior (p=0,03, p=0,039 e p=0,03, respectivamente) no carcinoma colorretal do que no adenoma e na mucosa não neoplásica adjacente. A coloração imuno-histoquímica dessas proteínas não apresentou diferenças significantes em relação às características clinicopatológicas do câncer colorretal e do adenoma. Conclusões Em adenomas, as menores expressões de betacatenina, axina 1 e GSK3β indicaram que o complexo de destruição da betacatenina estava conservado, enquanto que, no carcinoma colorretal, o aumento das expressões da betacatenina, GSK3β, 1 axina, e ubiquitina indicaram que o complexo de destruição de betacatenina estava alterado.

URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER.

BACKGROUND: The impact on quality of life attributed to treatment for rectal cancer remains high. Deterioration of the urinary function is a relevant complication within that context. OBJECTIVE: To detect the presence of urinary dysfunction and its risk factors among individuals underwent surgical treatment for rectal cancer. METHODS: The present prospective study analyzed 42 patients from both genders underwent surgical treatment for rectal adenocarcinoma with curative intent. The version of the International Prostatic Symptom Score (IPSS) questionnaire validated for the Portuguese language was applied at two time-points: immediately before and 6 months after surgery. Risk factors for urinary dysfunction were analysed by means of logistic regression and Student's t-test. RESULTS: Eight (19%) participants exhibited moderate-to-severe urinary dysfunction 6 months after surgery; the average IPSS increased from 1.43 at baseline to 4.62 six months after surgery (P<0.001). None of the variables assessed as potential risk factors exhibited statistical significance, i.e., age, gender, distance from tumour to anal margin, neoadjuvant therapy, adjuvant therapy, type of surgery, surgical approach (laparoscopy or laparotomy), and duration of surgery. CONCLUSION: This study identified an incidence of 19% of moderate to severe urinary dysfunction after 6 months surveillance. No risk factor for urinary dysfunction was identified in this population.

URINARY DYSFUNCTION AFTER SURGICAL TREATMENT FOR RECTAL CANCER / Disfunção urinária após tratamento cirúrgico do câncer de reto

BackgroundThe impact on quality of life attributed to treatment for rectal cancer remains high. Deterioration of the urinary function is a relevant complication within that context.ObjectiveTo detect the presence of urinary dysfunction and its risk factors among individuals underwent surgical treatment for rectal cancer.MethodsThe present prospective study analyzed 42 patients from both genders underwent surgical treatment for rectal adenocarcinoma with curative intent. The version of the International Prostatic Symptom Score (IPSS) questionnaire validated for the Portuguese language was applied at two time-points: immediately before and 6 months after surgery. Risk factors for urinary dysfunction were analysed by means of logistic regression and Student’s t-test.ResultsEight (19%) participants exhibited moderate-to-severe urinary dysfunction 6 months after surgery; the average IPSS increased from 1.43 at baseline to 4.62 six months after surgery (P<0.001). None of the variables assessed as potential risk factors exhibited statistical significance, i.e., age, gender, distance from tumour to anal margin, neoadjuvant therapy, adjuvant therapy, type of surgery, surgical approach (laparoscopy or laparotomy), and duration of surgery.ConclusionThis study identified an incidence of 19% of moderate to severe urinary dysfuction after 6 months surveillance. No risk factor for urinary dysfunction was identified in this population.

ContextoA perda de qualidade de vida atribuída ao tratamento do câncer retal continua elevada. Neste contexto, a deterioração da função urinária é complicação relevante.ObjetivoIdentificar disfunção urinária e seus fatores de risco em doentes submetidos ao tratamento cirúrgico do câncer de reto.MétodosRealizou-se estudo prospectivo com 42 doentes de ambos os sexos submetidos a tratamento cirúrgico com intenção curativa para adenocarcinoma de reto. Foi utilizado o questionário International Prostatic Symptom Score, validado na língua portuguesa, em dois períodos: imediatamente antes e após 6 meses do procedimento cirúrgico. Os fatores de risco para disfunção urinária foram analisados por regressão logística e teste t de Student.ResultadosApós 6 meses do procedimento cirúrgico, oito (19%) doentes apresentaram disfunção urinária moderada a grave e aumento na média do escore utilizado de 1,43 pontos no pré-operatório para 4,62 pontos no pós-operatório (P<0,001). A análise de fatores de risco para disfunção urinária não mostrou significância para as variáveis estudadas, idade, gênero, distância tumoral da margem anal, neoadjuvância, adjuvância, procedimento cirúrgico realizado, via de acesso cirúrgico (laparoscópica ou laparotômica) e tempo operatório.ConclusãoNos doentes com carcinoma retal operados com intenção curativa, a incidência de disfunção urinária moderada a grave após 6 meses da operação foi de 19%. Não foram identificados fatores de risco para disfunção urinária nesses doentes.

Carcinoembryoni antigen levels in the peripherl and mesenteric venous blood oof patients with rectal carcinoma / Niveis do antigeno carcinoembrionico no sangue venoso periferico e mesenterico em doentes com carcinoma retal

Context The serum carcinoembryonic antigen (CEA) is an important prognostic factor in colorectal cancer, however the rectum presents different routes of venous drainage, stating that the level of CEA in peripheral and mesenteric rectal tumors may be different, depending on the location of the tumor in the rectal segment. Objective The goal of this study was to evaluate the relationship between the peripheral and mesenteric venous levels of CEA and the association between these levels and the tumour location in the rectums of patients successfully operated on for rectal carcinoma. Methods Thirty-two patients who were surgically treated for rectal carcinoma were divided into patients with tumours located in the upper rectum (n = 11) or lower rectum (n = 21). The CEA values were assessed by electrochemiluminescence immunoassay. Serum and mesenteric CEA levels were associated with the tumour anatomopathological characteristics: location, histological type, cellular differentiation grade, depth of invasion into the rectal wall, angiolymphatic invasion, tumour, node, and metastasis staging; and the CEA index (≤1.0 or ≥1.0 ng /mL). Results Analysis of the serum CEA values using clinical and anatomopathological parameters revealed no significant association with tumour location, histological type, cellular differentiation grade, depth of invasion into the intestinal wall, and tumour, node, and metastasis staging. The mesenteric CEA levels were significantly associated with the tumour location (P = 0.01). The CEA values in the mesenteric venous blood and the presence of angiolymphatic invasion (P = 0.047) were significantly different. A significant relationship was found between the CEA index value and the rectal tumour location (P = 0.0001). Conclusions The CEA levels were higher in the mesenteric vein in tumours located in the upper rectum and in the presence of angiolymphatic invasion. CEA drainage from lower rectum adenocarcinomas ...

Contexto O antígeno carcinoembriônico (CEA) sérico é um importante fator de prognóstico do câncer coloretal, contudo o reto apresenta diferentes vias de drenagem venosa, indicando que o nível do CEA periférico e mesentérico nos tumores retais podem ser diferentes, na dependência da localização da neoplasia no segmento retal. Objetivo Avaliar em doentes operados curativamente de carcinoma do reto, a relação entre o nível venoso periférico e portal do CEA e a associação desses níveis com a localização da neoplasia no reto. Método Trinta e dois doentes operados por carcinoma retal foram divididos em pacientes com tumores situados no reto alto (n = 11) e no reto baixo (n = 21). A análise dos valores de CEA foi determinada por imunoensaio de eletroquimioluminescência. As dosagens do CEA sérico e mesentérico foram associadas aos aspectos anatomopatológicos da neoplasia (localização da neoplasia, tipo histológico, grau de diferenciação celular, profundidade de invasão na parede retal, invasão angiolinfática); estadiamento tumor, nódulo e metástase e; ao índice do CEA (≤1,0 ou ≥1,0 ng/mL). Resultados A análise dos valores de CEA sérico com os parâmetros clínicos e anatomopatológicos não revelou associação significante com a localização do tumor, tipo histológico, grau de diferenciação celular, nível de profundidade de invasão na parede intestinal e estadiamento tumor, nódulo e metástase. Os valores dos níveis mesentéricos do CEA apresentaram associação significante com a localização do tumor (P = 0,010). Observou-se diferença significante entre os valores do CEA no sangue venoso mesentérico e a presença de invasão ...

Predictive factors of hospitalization in children with acute asthma at a university emergency care unit.

OBJECTIVE: This study analyzed the factors that predicted the hospitalization of children with asthma following standardized treatment in emergency care unit (ECU). METHODS: This retrospective study examined data collected from the clinical records of children, 14 years or younger, who were diagnosed with asthma (often with bronchopneumonia, pneumonia, or other illnesses) and treated at the ECU of Santo André from January 2005 to December 2009. The following data were analyzed: month and year of care, child's age and sex, period of observation, and need for hospitalization. A pediatrician confirmed the clinical diagnoses of all participants. The children were first given clinical treatments and were then admitted to ECU for follow-up assessment. RESULTS: The number of hospital admissions was analyzed, and correlations were found with regard to this variable and child age (χ(2) = 166.9; P = 0.00001), the presence of associated illnesses (χ(2) = 63.8; P < 0.00001), and the observation period length (χ(2) = 11.4; P = 0.009). The number of hospital admissions was not correlated with child sex (χ(2) = 0.013; P = 0.9) or time of year (χ(2) = 15.8; P = 0.1). The 3-day observation period was not significant (P = 0.4) with regard to the remainder of the variables in the multiple logistic regression analysis. CONCLUSIONS: Age, mainly children younger than 1 year, the presence of associated illnesses, and the observation period length predicted the hospitalization of children with asthma following treatment in ECU. Sex and seasonality did not affect the need for hospitalization.

Primary epiploic appendagitis / Apendagite epiplóica primária

Primary epiploic appendagitis (PEA) is a seldom reported disease caused by spontaneous torsion of one or more epiploic appendices. The aim of this study is to describe two cases of PEA reviewing the main aspects of the diagnosis and treatment of disease. Case report: Case 1) Male patient, 55 years old, obese, with abdominal right iliac fossa (RIF) pain for two days. Abdominal examination showed pain on palpation in the RIF with rebound tenderness. Abdominal computed tomography identified lobulated lesion in the cecum, measuring 4.5 cm in diameter, which was suggestive of PEA or early neoplasm of the colon wall. The laparoscopic assessment confirmed the diagnosis of PEA and the appendix was removed. The patient had a satisfactory outcome, being discharged on the second postoperative day. Case 2) Female patient, obese, 47 years old, with abdominal pain for six days, with sudden RIF onset. She had pain at palpation with rebound tenderness. Acute diverticulitis was suspected and patient underwent abdominal CT that identified PEA in the sigmoid colon. After expectant management, the patient showed progressive improvement resuming her activities in seven days. PEA is a rarely recalled condition during the investigation of inflammatory acute abdomen which can be easily recognized by modern imaging methods of assessment. (AU)

Apendagite epiplóica primária (AEP) é uma enfermidade raramente descrita, ocasionada pela torção espontânea de um ou mais apêndices epiplóicos. O objetivo deste estudo é descrever dois casos de AEP revisando os principais aspectos do diagnóstico e tratamento da doença. Relato dos Casos: 1º) Homem, 55 anos, obeso com dor abdominal em FID há dois dias. No exame do abdômen apresentava dor à palpação na FID e descompressão brusca presente. A tomografia computadorizada do abdômen identificou lesão expansiva no ceco, lobulada, medindo 4,5 cm de diâmetro, suspeitando-se de AEP ou neoplasia primitiva da parede cólica. Durante a videolaparoscopia confirmou-se o diagnóstico de AEP sendo removido o apêndice comprometido. O doente apresentou evolução satisfatória recebendo alta no segundo dia. 2º) Mulher, obesa, 47 anos, com dor abdominal há seis dias, de início súbito na fossa ilíaca esquerda. Apresentava dor à palpação local com descompressão brusca presente. Com suspeita de diverticulite aguda foi submetida à TC do abdômen que identificou AEP do cólon sigmóide. Após conduta expectante apresentou melhora progressiva retomando suas atividades em sete dias. A AEP é uma enfermidade raramente suspeitada durante a investigação do abdômen agudo inflamatório, que pode ser reconhecida com facilidade pelos modernos exames de imagem. (AU)

APC protein immunoexpression in colorectal adenoma and adenocarcinoma / Imunoexpressão da proteína APC nos tecidos de adenoma e de adenocarcinoma colorretais

BACKGROUND: activation of the Wnt pathway by mutated APC gene is considered the initial event in colorectal carcinogenesis. The identification of these mutations can improve the specific treatment of the adenocarcinoma. OBJECTIVE: detect and evaluate wild-type APC protein in tissue from colorectal adenoma, adenocarcinoma and adjacent mucosa. METHODS: 42 patients that underwent surgery for adenocarcinoma and 53 patients with resected adenomas were studied. Tissue samples from the adenocarcinoma were obtained from the tumor and from adjacent non-neoplastic mucosa located 10 cm from the proximal margin of the tumor. Adenoma tissue was obtained from representative areas. Blocks of tissue microarray (TMA) were submitted to immunohistochemistry with anti-APC, with readings of positivity and intensity of immunostaining and the score of immune expression of APC protein was obtained. RESULTS: the APC protein immune expression score showed a significantly lower expression of APC protein in the adenoma when compared with the adenocarcinoma (p < 0.0001) and adjacent mucosa (p < 0.0001). The APC protein immune expression score in the colorectal mucosa and adjacent to the adenocarcinoma showed no significant difference (p = 0.24). CONCLUSIONS: the finding of decreased expression of APC protein in adenoma tissue may indicate that the mutated APC gene may contribute to the changes in the adenoma-carcinoma process of carcinogenesis sequence. The strong expression of protein APC in tissues from the carcinoma and adjacent mucosa suggests that in most patients in this series, the mutation of the APC gene did not participate in the oncogenesis mechanism. (AU)

RACIONAL: a ativação da via Wnt pelo gene APC mutado é considerado evento inicial da carcinogênese colorretal. A identificação dessas mutações pode tornar o tratamento do adenocarcinoma mais específico. OBJETIVO: detectar e avaliar a proteína APC não mutada em tecidos de adenoma, adenocarcinoma e mucosa adjacente. MÉTODO: estudados 42 doentes operados de adenocarcinoma e 53 com adenomas ressecados. Tecidos de adenocarcinoma foram obtidas da neoplasia e da mucosa adjacente não neoplásica situadas a 10 cm da margem proximal do tumor. Tecidos do adenoma foram obtidas de área representativa. Blocos de tissue microarray (TMA) foram submetidos a imuno-histoquímica com anticorpo anti-APC. Avaliadas a positividade e intensidade da expressão e obtidos escores da imunoexpressão da proteína APC. RESULTADOS: o escore da imunoexpressão da proteína APC no adenoma foi significantemente menor do que no adenocarcinoma (p < 0,0001) e na mucosa adjacente (p < 0,0001). O escore da imunoexpressão da proteína APC na mucosa adjacente e no adenocarcinoma não mostraram diferença significante (p = 0,24). CONCLUSÕES: a menor expressão da proteína APC no adenoma pode indicar que o gene APC mutado participa das alterações do processo adenoma-carcinoma. A forte expressão da proteína APC no CCR e na mucosa adjacente sugerem que a mutação do gene APC não participou da oncogênese. (AU)

Gallbladder-associated ectopic liver: A rare finding during a laparoscopic cholecystectomy.

INTRODUCTION: Ectopic hepatic tissue is due to an uncommon failure of embryological liver development that is rarely described in the world medical literature. The incidence of ectopic liver (EL) has been reported to be anywhere from 0.24% to 0.47% as diagnosed at laparotomy or laparoscopy. We describe a case of EL adherent to the gallbladder, removed at laparoscopic cholecystectomy. PRESENTATION OF CASE: A 37-year-old female was admitted for elective cholecystectomy having had an episode of acute cholecystitis provoked by gallstones. During the procedure, a 30mm×10mm×5mm section of EL tissue attached to the anterior wall of the gallbladder was identified and removed by en-bloc excision during laparoscopic cholecystectomy. Histological examination confirmed the absence of malignant degeneration of the hepatic tissue. The patient recovered well postoperatively and was discharged the day after the operation. She was well when seen six months later. DISCUSSION: EL has been reported in several sites, such as the gallbladder, gastrohepatic ligament, adrenal glands, esophagus, and thoracic cavity. EL is often clinically silent and discovered incidentally during abdominal surgical procedures or autopsies. Because patients with ectopic liver may suffer complications such as torsion, peritoneal bleeding, fatty change, and evolution to cirrhosis or malignant degeneration to hepatocellular carcinoma, any ectopic liver tissue needs to be correctly identified and removed. CONCLUSION: Despite the rare occurrence of EL, it should be recognized and removed by the surgeon to prevent a higher risk of complications and malignant transformation.

Carcinoembryonic antigen levels in the peripheral and mesenteric venous blood of patients with rectal carcinoma.

CONTEXT: The serum carcinoembryonic antigen (CEA) is an important prognostic factor in colorectal cancer, however the rectum presents different routes of venous drainage, stating that the level of CEA in peripheral and mesenteric rectal tumors may be different, depending on the location of the tumor in the rectal segment. OBJECTIVE: The goal of this study was to evaluate the relationship between the peripheral and mesenteric venous levels of CEA and the association between these levels and the tumour location in the rectums of patients successfully operated on for rectal carcinoma. METHODS: Thirty-two patients who were surgically treated for rectal carcinoma were divided into patients with tumours located in the upper rectum (n = 11) or lower rectum (n = 21). The CEA values were assessed by electrochemiluminescence immunoassay. Serum and mesenteric CEA levels were associated with the tumour anatomopathological characteristics: location, histological type, cellular differentiation grade, depth of invasion into the rectal wall, angiolymphatic invasion, tumour, node, and metastasis staging; and the CEA index (≤1.0 or ≥1.0 ng /mL). RESULTS: Analysis of the serum CEA values using clinical and anatomopathological parameters revealed no significant association with tumour location, histological type, cellular differentiation grade, depth of invasion into the intestinal wall, and tumour, node, and metastasis staging. The mesenteric CEA levels were significantly associated with the tumour location (P = 0.01). The CEA values in the mesenteric venous blood and the presence of angiolymphatic invasion (P = 0.047) were significantly different. A significant relationship was found between the CEA index value and the rectal tumour location (P = 0.0001). CONCLUSIONS: The CEA levels were higher in the mesenteric vein in tumours located in the upper rectum and in the presence of angiolymphatic invasion. CEA drainage from lower rectum adenocarcinomas preferentially occurs through the systemic pathway.

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment.

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

Biliopancreatic diversion with duodenojejunal exclusion associated with truncal vagotomy: a new proposal for type 2 diabetes mellitus treatment / Derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular: uma nova proposta para o tratamento do diabetes melito tipo 2

PURPOSE: To evaluate the effectiveness of the biliopancreatic diversion surgery with duodenojejunal exclusion in combination with truncal vagotomy in type 2 diabetes mellitus (T2DM) patients with overweight or class I or II obesity. METHODS: The study included ten patients with T2DM and class I or II obesity or overweight who were subjected to biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy. The blood glucose levels during the pre- and postoperative periods were compared using the Friedman test. The significance level adopted was 5%. RESULTS: There were significant differences between preoperative and postoperative blood glucose levels at three months (p=0.01), six months (p=0.001) and 12 months (p=0.001). There was also a significant difference between one month postoperative blood glucose and six months postoperative blood glucose (p=0.01). Glycosylated hemoglobin levels decreased in 80% of patients, there was marked improvement in their lipid profiles, and the average BMI reduction was 7.0±1.5 kg/m² at 12 months after the surgery. CONCLUSION: In patients with type 2 diabetes mellitus associated with class I/II obesity or overweight, performing biliopancreatic diversion with duodenojejunal exclusion in combination with truncal vagotomy resulted in glycemic control, reduction of excess weight, and improvement of lipid profile 12 months after the surgery.

OBJETIVO: Avaliar a eficácia da operação de derivação biliopancreática com exclusão duodeno-jejunal associada com vagotomia troncular em doentes com diabetes tipo 2 com sobrepeso ou obesidade classe I ou II. MÉTODOS: Foram estudados dez doentes com diabetes melito tipo 2 e sobrepeso ou obesidade grau I ou II submetidos à derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular. Os valores de glicemia no pré e no pós-operatório foram comparados pelo teste de Friedman. O nível de significância adotado foi de 5%. RESULTADOS: Houve diferença significante (p=0,01) nas glicemias pré e pós-operatórias de três meses, de seis meses (p=0,001) e de 12 meses (p=0,001). Houve diferença significante entre a glicemia pós-operatória de um mês e glicemia pós-operatória de seis meses (p=0,01). O nível de hemoglobina glicosilada reduziu-se em 80% dos doentes, houve melhora acentuada do perfil lipídico e a média da redução do IMC foi de 7,0±1,5 kg/m² após 12 meses da operação. CONCLUSÃO: No paciente com diabetes melito tipo 2 associado com sobrepeso ou obesidade grau I/II, a realização da derivação biliopancreática com exclusão duodeno-jejunal associada à vagotomia troncular proporcionou controle glicêmico, redução do excesso de peso e melhora do perfil lipídico após 12 meses da operação.

Manometria anorretal no divertículo de reto / Anorectal manometry in rectal diverticulum

Divertículo localizado no reto é um achado excepcional, estimando-se que existam pouco mais de 50 casos publicados. A doença apresenta aspectos controversos, quanto a ser de origem congênita ou adquirida. Recentemente, distúrbios defecação vêm sendo relacionado à maior possibilidade do desenvolvimento da doença. Contudo, até a presente data, as alterações manométricas em portadores de divertículo do reto ainda não foram estudadas. OBJETIVO: O objetivo do presente estudo é demonstrar os resultados de estudo eletromanométrico anorretal, realizado em dois doentes portadores divertículo do reto. CASUÍSTICA E MÉTODO: Um homem e uma mulher, com 56 e 58 anos, respectivamente, foram submetidos à colonoscopia, enema opaco, ultrassonografia endorretal e ressonância magnética da pelve, para confirmação e documentação diagnóstica de divertículo localizado no reto. Os enfermos foram submetidos à eletromanometria anorretal com cateter de oito canais sob perfusão de água a 0,3 ml/min/canal, através de sistema de infusão capilar pneumático e hidráulico. RESULTADOS: O resultado dos exames em ambos os doentes mostrou perfil pressórico esfincteriano normal, tanto em repouso, como em contração voluntária máxima, não se encontrando assimetrias esfincterianas. O reflexo reto-anal inibitório encontrava-se presente e dentro de valores normais, assim como a sensibilidade e complacência retal. A análise pelo vetor volume não mostrou alterações significativas concluindo-se por estudo manométrico ano-retal normal. CONCLUSÃO: O estudo manométrico anorretal não demonstrou existência de distúrbios pressóricos nos esfíncteres anorretais reforçando a possibilidade de que o divertículo de reto possa ter origem congênita, desenvolvendo-se em pontos onde exista maior fraqueza da parede retal.

Diverticulum located in the rectum is an exceptional find with fewer than 50 cases published. The etiology of the diverticulum of the rectum still has controversial aspects regarding its origin is congenital or acquired. Recently, alterations of the evacuative dynamic had been associated with the development of the disease. Nevertheless, until the present date, the manometric alterations in patients with diverticulum of the rectum were not studied. OBJECTIVE: The aim of the present study is to demonstrate the results of electromanometric study carried out in a patient with isolated diverticulum of the rectum. CASE REPORT: A man and a woman, 56 and 58 years-old, respectively, were submitted to colonoscopy, barium enema, endorectal ultrasound and magnetic resonance of the pelvis to diagnose and document the presence of diverticulum located in the rectum. The patients were submitted to manometry using catheter with eight-channel perfusion under water at 0.3 ml/min/channel, through pneumatic and hydraulic capillary infusion system. The anorectal manometry showed normally sphincter pressure profile both in rest and squeezes pressure state, and did not find sphincter asymmetries. The anorectal inhibition reflex was present with normal values and the sensibility and rectal complaisance were between the normal limits. The vector volume analysis did not show any significant alterations and it was concluded by normal manometric anorectal study. CONCLUSION: The anorectal manometry study did not demonstrate the existence of pressure disturbances in anorectal sphincter, enhancing the possibility that the rectal diverticulum can be congenital, developing at points where there is major weakness of the rectal wall.

Níveis dos marcadores CEA e CA 19-9 no soro e no lavado peritoneal na avaliação do comprometimento linfonodal do carcinoma gástrico / Levels of CEA and CA 19-9 markers in sera and peritoneal wash and the evaluation of lymph node involvement in gastric carcinoma

Introdução: A recidiva peritoneal precoce do carcinoma gástrico operado com intenção curativa constitui grande desafio para seu tratamento e prevenção. Objetivo: Analisar a relação entre os níveis do marcador tumoral CEA e CA 19-9 no sangue e no lavado peritoneal e o comprometimento linfonodal do carcinoma gástrico. Métodos: Foram estudados 46 doentes operados por carcinoma gástrico. Vinte e nove (63

) eram do sexo masculino e 17 (37

Levels of carcinoembryonic antigen and CA 19-9 in the sera and peritoneal washing of patients undergoing surgical treatment for gastric carcinoma.

BACKGROUND: Early peritoneal recurrence of gastric carcinoma following curative resection remains a great challenge in the treatment and prevention of this disease. AIM: To analyze the relationship between levels of tumor markers, carcinoembryonic antigen (CEA) and CA 19-9 in the sera and peritoneal washing, and anatomopathological aspects of the gastric carcinoma. METHODS: Of the 46 patients in the study, 29 (63.0%) were males and 17 (37.0%) females. Mean age was 63.6 +/- 11.7 years (31 to 91 years). Peripheral venous blood samples were collected from the upper limb vein from both patient groups after anesthetic induction, in order to determine serum levels of CEA and CA 19-9. After the end of the procedure, 50 mL of physiologic solution was introduced into the bottom of the Douglas sack and a portion aspirated to determine CEA and CA 19-9 levels in the peritoneal washing. Levels of CEA and CA 19-9 in the sera and peritoneal washing were compared to the following variables: lesion diameter < or = 4 cm or > 4 cm, lymph node involvement, angiolymphatic invasion, depth of invasion into gastric wall, and initial or late stage. RESULTS: Sera CEA levels were significantly higher in patients with lesions >5 cm. CEA levels in the sera and peritoneal washing were significantly greater in patients with signet ring cell gastric carcinoma. In addition, levels of CEA in peripheral blood and peritoneal washing showed significant association with the degree of carcinoma penetration into the gastric wall, while sera CEA was significantly higher in patients at more advanced stages. There was no significant difference between sera and peritoneal CEA values regarding grade of differentiation. Patients with gastric lesions measuring > 5 cm and more differentiated lesions had significantly higher sera CA 19-9 values. In patients with lymph nodes invasion by gastric carcinoma, CA 19-9 levels in peritoneal washing were significantly higher than in peripheral blood. Levels of CA 19-9 in peritoneal washing were significantly greater at advanced stages than the initial stage of the gastric carcinoma. CONCLUSIONS: Elevated levels of CA 19-9 in peritoneal washing were significantly associated with more advance stages of gastric carcinoma and was more reliable predictive factor for staging than sera CA 19-9 levels. CEA levels in the sera more accurately reflected neoplasia stage than levels in peritoneal washing.

Levels of carcinoembryonic antigen and CA 19-9 in the sera and peritoneal washing of patients undergoing surgical treatment for gastric carcinoma / Níveis do antígeno carcinoembriônico e do CA 19-9 no soro e no lavado peritonial em doentes submetidos ao tratamento cirúrgico do carcinoma gástrico

BACKGROUND: Early peritoneal recurrence of gastric carcinoma following curative resection remains a great challenge in the treatment and prevention of this disease. AIM: To analyze the relationship between levels of tumor markers, carcinoembryonic antigen (CEA) and CA 19-9 in the sera and peritoneal washing, and anatomopathological aspects of the gastric carcinoma. METHODS: Of the 46 patients in the study, 29 (63.0 percent) were males and 17 (37.0 percent) females. Mean age was 63.6 ± 11.7 years (31 to 91 years). Peripheral venous blood samples were collected from the upper limb vein from both patient groups after anesthetic induction, in order to determine serum levels of CEA and CA 19-9. After the end of the procedure, 50 mL of physiologic solution was introduced into the bottom of the Douglas sack and a portion aspirated to determine CEA and CA 19-9 levels in the peritoneal washing. Levels of CEA and CA 19-9 in the sera and peritoneal washing were compared to the following variables: lesion diameter ≤4 cm or >4 cm, lymph node involvement, angiolymphatic invasion, depth of invasion into gastric wall, and initial or late stage. RESULTS: Sera CEA levels were significantly higher in patients with lesions >5 cm. CEA levels in the sera and peritoneal washing were significantly greater in patients with signet ring cell gastric carcinoma. In addition, levels of CEA in peripheral blood and peritoneal washing showed significant association with the degree of carcinoma penetration into the gastric wall, while sera CEA was significantly higher in patients at more advanced stages. There was no significant difference between sera and peritoneal CEA values regarding grade of differentiation. Patients with gastric lesions measuring > 5cm and more differentiated lesions had significantly higher sera CA 19-9 values. In patients with lymph nodes invasion by gastric carcinoma, CA 19-9 levels in peritoneal washing were significantly higher than in ...

RACIONAL: A recidiva peritonial precoce do carcinoma gástrico operado com intenção curativa continua sendo um grande desafio do seu tratamento e prevenção. OBJETIVO: Analisar a relação entre os níveis do marcador tumoral antígeno carcinoembriônico (CEA) e CA 19-9 no sangue e no lavado peritonial e os aspectos anatomopatológicos do carcinoma gástrico. MÉTODO: Dos 46 doentes do estudo, 29 (63,0 por cento) eram do sexo masculino e 17 (37,0 por cento) do feminino. A média de idade foi de 63,6 ± 11,7 anos (31 a 91 anos). Após a indução anestésica, o sangue venoso periférico foi coletado de veia do membro superior para a determinação do nível sérico do CEA e CA 19-9. Após o término do procedimento operatório foram derramados 50 mL de solução fisiológica no fundo de saco de Douglas, aspirada alíquota que foi encaminhada para a determinação do nível no lavado peritonial do CEA e CA 19-9. O nível do CEA e do CA 19-9 sérico e no lavado peritonial foram relacionados às seguintes variáveis: diâmetro da lesão ≤4 cm ou >4 cm, comprometimento linfonodal, invasão angiolifática, profundidade de invasão na parede gástrica e estádio inicial ou tardio. RESULTADOS: Em relação ao CEA, o nível sérico foi significantemente maior nos doentes com o diâmetro da lesão >5 cm. O nível de CEA sérico e no lavado peritonial foi significantemente maior nos doentes com carcinoma gástrico com células em anel de sinete. O nível de CEA no sangue periférico e no lavado peritonial mostrou relação significante com o nível de penetração do carcinoma na parede gástrica, e o CEA sérico foi significantemente mais elevado nos doentes com estádio mais avançados. Não houve diferença significante entre os valores do CEA sérico e peritonial nos carcinomas mais diferenciados em relação aos menos diferenciados. No tocante ao CA 19-9, os enfermos com lesões gástricas com diâmetro >5 cm e mais diferenciadas exibiram valores séricos de CA 19-9 significantemente maiores. Nos doentes ...

Irrigação da curvatura menor do estômago após vagotomia gástrica proximal: estudo morfométrico em cães / The lesser bending irrigation of the stomach after proximal gastric vagotomia: morfométrico study in dogs

Objetivos: Avaliar os efeitos da vagotomia gástrica proximal (VGP) sobre a vascularização da curvatura gástrica menor. Material e Método: Foram utilizados 15 cães, distribuídos em dois grupos experimentais: grupo A (grupo controle), com animais submetidos à tração gástrica e grupo B, animais submetidos à VGP. Todos os cães foram mortos no 7º pós-operatório e imediatamente foi infundido corante xantínico na aorta torácica à pressão de 12 mmHg. O estômago, depois de perfundido com o corante, foi isolado das demais vísceras e fotografado pelas superfícies externa e interna. Nos animais do grupo B, as áreas coradas e desprovidas de coloração foram mensuradas por meio de três métodos morfométricos: decomposição milimétrica, planimétrico e morfometrico computadorizado. A análise estatística dos resultados, comparando os dois grupos experimentais, foi feita pelo teste de Mann-Whitney. A análise de variância entre os três métodos de calculo utilizados foi feita pelos testes Anova e de Kruskal-Wallis. Resultados: Verificou-se que nos animais do grupo A houve completo preenchimento da superfície mucosa gástrica pela substância corante, enquanto que em todos os animais do grupo B houve formação de área desprovida de coloração na região da curvatura gástrica menor e que representou 29% de toda a superfície mucosa do órgão (p< 0,05). Conclusões: Concluiu-se que a VGP pode provocar formação de área potencialmente sujeita à isquemia na região da curvatura gástrica menor.