Common bile duct stones: analysis of the videolaparoscopic surgical treatment.

CONTEXT: About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy. OBJECTIVE: To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis. METHODS: Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis). RESULTS: The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series. CONCLUSION: The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results.

Common bile duct stones: analysis of the videolaparoscopic surgical treatment / Coledocolitíase: análise do tratamento videolaparoscópico

CONTEXT: About 9% of the Brazilian population has gallstones and the incidence increases significantly with aging. The choledocholithiasis is found around 15% of these patients, and a third to half of these cases presented as asymptomatic. Once the lithiasis in the common bile duct is characterized through intraoperative cholangiography, the laparoscopic surgical exploration can be done through the transcystic way or directly through choledochotomy. OBJECTIVE: To evaluate the results and outcomes of the laparoscopic treatment of common bile duct lithiasis. METHODS: Seventy consecutive patients were evaluated. They prospectively underwent the treatment of the lithiasis in the common bile duct and the exploration ways were compared according to the following parameters: criteria on their indication, success in the clearance, surgical complications. It was verified that about ½ of the choledocholithiasis carriers did not show any expression of predictive factors (clinical antecedents of jaundice and/or acute pancreatitis, compatible sonographic data and the pertaining lab tests). The laparoscopic exploration through the transcystic way is favored when there are no criteria for the practice of primary choledochotomy, which are: lithiasis in the proximal bile duct, large (over 8 mm) or numerous calculi (multiple calculosis). RESULTS: The transcystic way was employed in about 50% of the casuistic and the choledochotomy in about 30%. A high success rate (around 80%) was achieved in the clearance of the common bile duct stones through laparoscopic exploration. The transcystic way, performed without fluoroscopy or choledochoscopy, attained a low rate of success (around 45%), being 10% of those by transpapilar pushing of calculi less than 3 mm. The exploration through choledochotomy, either primary or secondary, if the latter was performed after the transcystic route failure, showed high success rate (around 95%). When the indication to choledochotomy was primary, the necessity for choledochoscopy through choledochotomy to help in the removal of the calculi was 55%. However, when choledochotomy was performed secondarily, in situations where the common bile duct diameter was larger than 6 mm, the use of choledochoscopy with the same purpose involved about 20% of the cases. There was no mortality in this series. CONCLUSION: The laparoscopic exploration of the common bile duct was related to a low rate of morbidity. Therefore, the use of laparoscopy for the treatment of the lithiasis in the common bile duct depends on the criteria for the choice of the best access, making it a safe procedure with very good results.

CONTEXTO: Aproximadamente 9% da população brasileira apresenta colecistolitíase e esta incidência aumenta significativamente com o envelhecimento. A coledocolitíase é encontrada em torno de 15% destes pacientes, e de um terço a metade destes casos apresenta-se de maneira assintomática. Uma vez que a litíase do ducto biliar comum é caracterizada através de colangiografia intra-operatória, a exploração cirúrgica laparoscópica pode ser feita através da via transcística, ou diretamente através de coledocotomia. OBJETIVO: Avaliar os resultados do tratamento laparoscópico da coledocolitíase. MÉTODOS: Setenta pacientes foram avaliados prospectivamente. Todos foram submetidos ao tratamento da coledocolitíase por videolaparoscopia, e as formas de exploração foram comparadas de acordo com os seguintes parâmetros: os critérios de sua indicação, o sucesso no clareamento da via biliar, complicações cirúrgicas. A exploração laparoscópica transcística foi favorecida quando não há critérios para a prática de coledocotomia primária, sendo estes litíase do ducto biliar proximal, cálculos grandes (mais de 8 mm) ou calculose múltipla. RESULTADOS: Verificou-se que cerca de um terço dos doentes com coledocolitíase não mostraram qualquer expressão de fatores preditivos (antecedentes clínicos de icterícia e/ou pancreatite aguda, suspeita ultrassonográfica ou alterações de testes laboratoriais relacionados à coledocolitíase). A exploração transcística foi empregada em cerca de 50% dos casos e a coledocotomia em cerca de 30%. A depuração da via biliar através da laparoscopia foi alcançada em 80% dos casos. A exploração transcística, realizada sem fluoroscopia ou coledocoscopia, atingiu baixa taxa de sucesso (em torno de 45%), sendo 10% desses casos com passagem transpapilar de cálculos com menos de 3 mm. A exploração por coledocotomia, primária ou secundária, quando esta foi realizada após o insucesso da via transcística, mostrou alta taxa de sucesso (em torno de 95%). Quando a indicação para coledocotomia era primária, a necessidade de visualização direta através da coledocoscopia para ajudar na remoção dos cálculos foi de 55%. No entanto, quando foi realizada coledocotomia secundariamente, nas situações em que o diâmetro do ducto biliar comum foi maior do que 6 mm, o uso de coledocoscópio com o mesmo propósito foi necessário em cerca de 20% dos casos. Não houve mortalidade nesta série. CONCLUSÃO: A exploração laparoscópica da via biliar principal está relacionada com baixa taxa de morbidade. Portanto, o uso da laparoscopia para o tratamento da coledocolitíase depende dos critérios para a escolha do melhor acesso, tornando-se procedimento seguro, com resultados bastante satisfatórios.

The main hepatic anatomic variations for the purpose of split-liver transplantation.

BACKGROUND/AIMS: Variant hepatic anatomy must be recognized and appropriately managed during split-liver transplantation to ensure complete vascular and biliary supply to both grafts. The aim of this study is to demonstrate the importance of an assessment of the hepatic anatomical structures for the purpose of split-liver transplantation. METHODOLOGY: Human cadaveric livers (n = 60) were obtained from routine autopsies. The cadavers and the livers had to comply with the following requirements: 1) minimum age 18 years: 2) no liver pathology to be expected from medical history and 3) no liver pathology noted at the autopsy. Resections were carried out en bloc with liver, celiac trunk, left gastric artery, lesser omentum, superior mesenteric artery and head of the pancreas. The main anatomical structures of the liver as hepatic artery, portal vein, biliary tree and hepatic veins were dissected out and recorded in detail also correlating to hepatic segments for application of the liver splitting. RESULTS: The right, the median and left hepatic vein is unique, respectively, in 59 (98.3%), 53 (88.3%) and 46 (76.3%) cases. The portal vein trunk has been divided into right and left branch in 59 (98.3%) cases. A median branch appeared in 9 (15.2%) cases and no bifurcation of the portal vein occurred in 1 (1.6%) case. The right and left hepatic ducts were multiple, respectively, 47 (78.3%) and 57 (95%) cases, however, the median hepatic duct, was unique in 16 (26.6%) cases. Looking at the intrahepatic distribution of the right hepatic duct we found four branches in 28 (59%) cases, towards segments V, VI, VII, VIII; two branches in 11 (23%) cases, towards segments V, VI and two branches in 8 (17%) cases, towards segments VII, VIII. Fifty-seven cadavers had multiple left hepatic ducts. The intrahepatic dissection showed that the major branches distribution were towards hepatic segments II and III. Three separate branches of the left hepatic duct were found, in 11 (19%) cases towards hepatic segments II, III and IV. Two intrahepatic ducts, coming from hepatic segments V and VI, drained separate to left intrahepatic biliary tree in 1 (2%) case. The arterial irrigation of the liver was made basically by right and left hepatic artery, only in 9 (15%) cases was there a median hepatic artery. Right hepatic artery, coming from the superior mesenteric artery, was present in 15 (25%) cases and left hepatic artery originating from left gastric artery in only 2 (3.3%) cases. Left hepatic artery had two exceptional origins, in 1 (1.6%) case coming directly from the abdominal aorta and in another from the superior mesenteric artery. The right and left hepatic artery was accessory, respectively, in 11 (18.3%) and 2 (3.3%) cases. Right hepatic artery was dominant in 4 (6.6%) cases. The median hepatic artery directed, respectively, to segment IV in 6 (10%) and to segment II and III in 3 (4.9%) cases. CONCLUSIONS: The study has shown that technique of controlled liver splitting for transplantation in two recipients could be an acceptable method for increasing the number of liver allografts. The anatomical and technical details of the splitting procedure are critical to the success of this technique. Good graft function and avoidance of complications depends on each graft having an intact arterial and portal blood supply as well as biliary and venous drainage from all retained liver segments. The absence of bifurcation of the portal vein, is a rare anomaly, and would certainly contraindicate the partition of the liver.

Lugol staining and histological evaluation of esophageal mucosa in achalasia.

BACKGROUND/AIMS: Esophageal cancer in achalasia is often diagnosed in the advanced stage, which makes for a poor prognosis. Therefore, the aim of this study was to evaluate the macroscopic and histological features of the esophageal mucosa in order to improve the early detection of cancer. METHODOLOGY: We studied the macroscopic features of esophageal mucosa using Lugol's solution and compared them with histological analysis of the entire mucosa in 20 esophagectomy specimens resected for achalasia. Intraepithelial neoplasia, when detected, was selected for DNA ploidy analysis through static cytometry. RESULTS: Macroscopically, the mucosa showed opacification and/or diffuse irregularities in 19 specimens. Advanced squamous cell carcinoma was diagnosed in 2 cases. Using Lugol, the esophageal mucosa acquired irregular brownish color. Clear unstained areas were circumscribed in 5 esophagi. They were macroscopically defined as ulcer, neoplasia (2 cases) and mucosal irregularities (2 cases). The histological analysis showed ulcer, squamous cell carcinoma (2 cases), Barrett's esophagus and esophagitis, respectively. The histological study of the stained mucosa revealed minute foci of DNA aneuploid intraepithelial neoplasia in 4 cases. CONCLUSIONS: Macroscopic examination using Lugol failed to identify minute foci of early carcinoma. The stained mucosa does not exclude the esophageal cancer risk in achalasia.

Videolaparoscopic cholecystectomy. Analysis of the clinical and functional aspects of mechanical lifting of the abdominal wall

BACKGROUND: Mechanical lifting of the abdominal wall, a method based on traction and consequent elevation of the abdominal wall, is an alternative procedure to create enough intra-abdominal space necessary for videolaparoscopic surgery, dispensing the need for intraperitoneal gas insufflation. OBJECTIVE: This study aims to evaluate the technical feasabilility of this procedure to carry out a videolaparoscopic cholecystectomy, while analyzing the clinical and functional aspects of this technique. PATIENTS AND METHODS: In the Digestive Tract Surgery Discipline of the Medical School at the University of Sao Paulo, Sao Paulo, SP, Brazil, was created the equipment to perform videolaparoscopic surgery using this method. The equipment has two sections: an external part which consisted of a frame attached to the operating table, inside which there is a sliding steel cable, moved by a ratched which is located at the lower end of one of the frame rods; the internal rod, the support, has an "L" shape, and its horizontal branch is made up of three turning rods and which is connected to the steel cable after insertion into the abdominal cavity. Ten patients underwent videolaparoscopic cholecystectomy using this equipment. The time taken to install the equipment, the operating area characteristics, the interference from the lifting equipment on surgical movements and on the intra-operative cholangiography, the measurements made of the force used during traction and extension of the abdominal wall elevation, and the medication required for postoperative analgesia were all evaluated. RESULTS: There were no intra-operative complications, and in none of the cases was it found necessary to convert to open surgery. We considered the insertion a safe and uncomplicated procedure, and the traction system efficient. Apart from the elevation of the abdominal wall, the distribution of the viscera inside the abdominal cavity is fundamental for the operating area. Depending on the position of the epigastric trocar, the lifting equipment can interfere with the surgical instruments mobility. It may be necessary to reposition the support to perform the intra-operative cholangiography. The tensional force applied to the peritoneal surface by the lifting rods is small, and no additional postoperative pain was observed using this procedure.

Long term (five-year) survival following radical surgical treatment plus adjuvant chemotherapy (FAM) in advanced gastric cancer: a controlled study

Several drugs and their associations are being used for adjuvant or complementary chemotherapy with the aim of improving results of gastric cancer treatment. The objective of this study was to verify the impact of these drugs on nutrition and on survival rate after radical treatment of 53 patients with gastric cancer in stage III of the TNM classification. A control group including 28 patients who had only undergone radical resection was compared to a group of 25 patients who underwent the same operative technique followed by adjuvant polychemotherapy with FAM (5-fluorouracil, Adriamycin, and mitomycin C). In this latter group, chemotherapy toxicity in relation to hepatic, renal, cardiologic, neurological, hematologic, gastrointestinal, and dermatological functions was also studied. There was no significant difference on admission between both groups in relation to gender, race, macroscopic tumoral type of tumor according to the Borrmann classification, location of the tumor in the stomach, length of the gastric resection, or response to cutaneous tests on delayed sensitivity. Chemotherapy was started on average, 2.3 months following surgical treatment. Clinical and laboratory follow-up of all patients continued for 5 years. The following conclusions were reached: 1) The nutritional status and incidence of gastrointestinal manifestation were similar in both groups; 2) There was no occurrence of cardiac, renal, neurological, or hepatic toxicity or death due to the chemotherapeutic method per se; 3) Dermatological alterations and hematological toxicity occurred exclusively in patients who underwent polychemotherapy; 4) There was no significant difference between the rate and site of tumoral recurrence, the disease-free interval, or the survival rate of both study groups; 5) Therefore, we concluded, after a 5-year follow-up, chemotherapy with the FAM regimen did not increase the survival rate

Evoluçäo clínica de pacientes com hipercolesterolemia familiar e doença coronaria submetidas a derivaçäo ileal parcial (bypass ileal) / Clinical outcome of patients with familial hypercholesterolemia and coronary artery disease undergoing partial ileal bypass surgery

Familial hypercholesterolemia is characterized by high serum levels of total cholesterol and LDL-cholesterol. It may be homozygous or heterozygous. In homozygous patients, LDL-cholesterol levels range from 500 to 1000mg/dL and coronary artery disease is precocious, usually manifesting itself between the 2nd and 3rd decades of life. The diagnosis is often made by the presence of xanthoma tuberosum and tendinous xanthomas that appear between the 1st and 2nd decades of life. The use of high doses of statins or even unusual procedures (apheresis, partial ileal bypass surgery, liver transplantation, gene therapy), or both, is necessary for increasing survival and improving quality of life, because a reduction in cholesterol levels is essential for stabilizing the coronary artery disease and reducing xanthomas. We report our experience with 3 patients with xanthomatous familial hypercholesterolemia and coronary artery disease, who underwent partial ileal bypass surgery. Their follow-up over the years (approximately 8 years) showed a mean 30 percent reduction in total cholesterol, with a significant reduction in the xanthomas and stabilization of the coronary artery disease

Colecistectomia laparoscópica - estruturação de um modelo de trabalho / Laparoscopic cholecystectomy - structure of a working model

São apresentados os resultados de 1772 colecistectomias videolaparoscópicas, sendo 1700 consecutivas sem mortalidade e baixa morbidade e rápida recuperação pós-operatória. Salienta-se a importância da sistematização técnica adotada para tais resultados, bem como do uso de instrumentos especiais de dissecção. É apresentada a estruturação de um modelo de trabalho para formação do cirurgião em cirurgia laparoscópica do aparelho digestivo, de maneira progressiva e sistematizada. O modelo implantado de formação e preparo do cirurgião, com rigor, profundidade e seriedade, é certamente responsável pelos resultados do nível de excelência obtidos

Fatal pulmonary thromboembolism in gastrectomy intraoperative procedures by gastric adenocarcinoma: case report

Relata-se um caso de paciente com adenocarcinoma gastrico com indicacao de gastrectomia. O ato operatorio transcorreu sem anormalidades. Foi realizada gastrectomia subtotal paliativa, pois encontrou-se linfonodos para-aorticos comprometidos pela neoplasia, confirmado pelo exame anatomo-patologico de congelacao realizado no decorrer da intervencao. Ao fim da confeccao da gastroentero-anastomose o paciente passou a apresentar bradicardia intensa: 38 batimentos por minuto (bpm), hipotensao arterial, alteracoes do tracado do eletrocardiograma (Supra-desnivelamento do segmento ST) e parada cardiaca. Realizadas as manobras de ressucitacao com sucesso temporario, ja que a seguir o paciente apresentou novo colapso circulatorio, sendo novamente recuperado, finalmente a terceira parada cardiaca foi irreversivel e constatou-se o obito intra-operatorio

Tunelização esofágica na fístula esofagotraqueobrônquica / Esophageal intubation for tracheo-esophageal fistula

Foram estudados 121 casos de câncer avançado do esôfago e da cárdia submetidos a tunelização esofágica por via endoscópica ou cirúrgica. Os doentes foram avaliados, tratados e seguidos segundo protocolo que constou de avaliação clínica, exames subsidiários, estadiamento, tratamento, avaliação intra e pós-operatória imediata. Verificaram-se a taxa de mortalidade, período de internação, complicações tardias, sobrevida e causa de óbito. Foram submetidos a tunelização cirúrgica 69 (53 por cento) doentes, e 52 (47 por cento) a tunelização endoscópica. Nos 17 casos de fístula esofagotraqueobrônquica houve sua oclusão eficiente pela tunelização endoscópica em 80 por cento dos casos, com mortalidade de 13,3 por cento, credenciando o método para tratamento dessa complicação tumoral. Os resultados obtidos com a tunelização endoscópica e cirúrgica recomendam seu uso em doentes com câncer avançado do esôfago e da cárdia

Detection of codon 12 mutation in the K-ras oncogene in pancreatic tumors

Muitos dos oncogenes detectados em neoplasias malignas humanas pertencem a familia do gene ras. Mutacoes nos codons 12, 13 ou 61 em um dos tres genes ras; H-ras, K-ras e N-ras, convertem esses genes em oncogenes ativos. Ensaios rapidos para deteccao dessas mutacoes pontuais, tais como a reacao em cadeia de polimertizacao tem sido desenvolvidos nas ultimas decadas e usados para investigar o papel dos genes ras mutados na patogenese de tumores humanos...

Clinical use of growth hormone and glutamine in short bowel syndrome

Hormonio de crescimento (GH) e glutamina(GLN) sao fatores troficos da mucosa intestinal, utilizados experimentalmente pos ressecao intestinal macica. O uso clinico de GH e GLN em sindrome do intestino curto (SIC) ainda nao esta padronizado...

Neoplasias sincronicas de esofago e estomago: importancia diagnostica e terapeutica / Simultaneous esophageal and gastric carcinoma: the importance of the diagnosis and treatment

A associacao entre o cancer esofagico e o gastrico tem sido evidenciada com maior frequencia nos ultimos anos devido aos avancos nos metodos de investigacao diagnostica. O estomago e o orgao habitualmente usado para as reconstrucoes apos esofagectomia por patologia benigna ou maligna. A correta avaliacao da mucosa gastrica no pre operatorio e imperativa, uma vez que pode ocorrer associacao entre carcinoma epidermoide do esofago e adenocarcinoma gastrico. E salientada a importancia da propedeutica gastrica pre-operatoria e, nos tumores estenosantes do esofago, a necessidade de inspecionar cuidadosamente o estomago no intra-operatorio

Estudo comparativo entre a acurácia da ultra-sonografia intra-retal e a do toque retal no estadiamento do câncer do reto / Comparative study of the accuracy of intrarectal ultrasound and rectal examination in the staging of rectal cancer

O tratamento adequado do câncer retal requer conhecimento preciso da extensäo local e sistêmica da doença. O toque retal, único método utilizado para avaliar localmente estes tumores até recentemente, tem boa precisäo em mäos experientes, porém limita-se a variaçöes individuais, bem como dificilmente define o acometimento dos linfonodos. A tomografia computadorizada, introduzida no início da década de 80, tem-se mostrado confiável apenas para o estadiamento dos tumores avançados do reto; näo demonstra as lesöes menores que um centímetro e nem a presença de linfonodos pequenos, além de apresentar dificuldades operacionais e custo alto. Já a ultra-sonografia intra-retal (USIR) tem sido descrita como método confiável para a avaliaçäo dos tumores retais. Na tentativa de elucidar a validade da utilizaçäo deste método, comparando-o ao toque retal, foi realizado trabalho prospectivo, o qual incluiu 52 indivíduos: 42 eram portadores de câncer do terço médio ou distal do reto e 10 näo tinham afecçäo retal. O aparelho utilizado foi da marca Aloka, modelo 650. Todos os indivíduos foram previamente submetidos ao exame de toque retal, cujos achados foram confrontados com aqueles da ultra-sonografia...