EUS-guided choledochoduodenostomy for biliary drainage in unresectable pancreatic cancer: a case series.

CONTEXT: Endoscopic retrograde cholangiopancreatography (ERCP) is the procedure of choice for biliary decompression in patients with unresectable pancreatic cancer. However, it may be unsuccessful in 3 to 10% of cases. When ERCP is unsuccessful, the usual alternatives are percutaneous transhepatic biliary drainage or surgery. Recently, several authors have reported the use of EUS-guided biliary drainage in patients with malignant biliary obstructions, with acceptable success and complication rates. We describe three cases of unresectable pancreatic cancer associated with obstructive jaundice, treated by EUS-guided biliary drainage. CASE REPORT: Three patients with unresectable pancreatic cancer, associated with obstructive jaundice, were included. ERCP was unsuccessful because of complete tumor obstruction of the distal common bile duct and papilla invasion. An EUS-guided rendezvous maneuver was attempted, without success. Then, EUS-guided choledochoduodenostomy, with a partially covered self-expanding metal stent, was performed in the same procedure. There were no early complications and the procedure was also clinically effective in relieving jaundice in all cases. CONCLUSIONS: EUS-guided biliary drainage is a feasible alternative to percutaneous transhepatic biliary drainage or surgery in unresectable pancreatic cancer with obstructive jaundice when ERCP fails. However, the development of new specific instruments and studies comparing this procedure with percutaneous transhepatic biliary drainage and surgery are needed.

Predictive factors for local recurrence and incomplete resection of early gastric cancer treated by endoscopic resection: a Western experience.

BACKGROUND: Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases. OBJECTIVES: To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year. METHODS: From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence). RESULTS: Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006). CONCLUSIONS: A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.

[Selection and use of anti-infective agents for intra-abdominal infections]. / Seleção e uso de antibióticos em infecções intra-abdominais.

BACKGROUND: Intra-abdominal infections are common and are associated with elevated morbidity and mortality. The microorganisms that cause intra-abdominal infections are usually from the gastrointestinal flora, mainly E. coli and Bacteroides fragilis. AIM: To present a review of the selection and use of antibiotics in intra-abdominal infections. CONCLUSIONS: Appropriate use of antibiotics is essential to control infection and to reduce treatment failure. Antibiotics are initiated whenever intra-abdominal infection is suspected and the antimicrobial agents are selected based on the most common microorganisms involved. In addition, efficacy, cost, safety, and posologic regimen are considered for an appropriated selection. Antibiotic regimen is different whether the infection is acquired in the community or at hospital due to the more resistant flora in the latter.

II Brazilian consensus statement on endoscopic ultrasonography.

BACKGROUND AND OBJECTIVES: At the time of its introduction in the early 80s, endoscopic ultrasonography (EUS) was indicated for diagnostic purposes. Recently, EUS has been employed to assist or to be the main platform of complex therapeutic interventions. METHODS: From a series of relevant new topics in the literature and based on the need to complement the I Brazilian consensus on EUS, twenty experienced endosonographers identified and reviewed the pertinent literature in databases. The quality of evidence, strength of recommendations, and level of consensus were graded and voted on. RESULTS: Consensus was reached for eight relevant topics: treatment of gastric varices, staging of nonsmall cell lung cancer, biliary drainage, tissue sampling of subepithelial lesions (SELs), treatment of pancreatic fluid collections, tissue sampling of pancreatic solid lesions, celiac neurolysis, and evaluation of the incidental pancreatic cysts. CONCLUSIONS: There is a high level of evidence for staging of nonsmall cell lung cancer; biopsy of SELs as the safest method; unilateral and bilateral injection techniques are equivalent for EUS-guided celiac neurolysis, and in patients with visible ganglia, celiac ganglia neurolysis appears to lead to better results. There is a moderate level of evidence for: yield of tissue sampling of pancreatic solid lesions is not influenced by the needle shape, gauge, or employed aspiration technique; EUS-guided and percutaneous biliary drainage present similar clinical success and adverse event rates; plastic and metallic stents are equivalent in the EUS-guided treatment of pancreatic pseudocyst. There is a low level of evidence in the routine use of EUS-guided treatment of gastric varices.

Transrectal ultrasound - Techniques and outcomes in the management of intestinal endometriosis.

The widespread use of endoscopic ultrasound has facilitated the evaluation of subepithelial and surrounding lesions of the gastrointestinal tract. Deep pelvic endometriosis, with or without infiltration of the intestinal wall, is a frequent disease that can be observed in women in their fertile age. Patients of this disease may present nonspecific signs and symptoms or be completely asymptomatic. Laparoscopic surgical resection of endometriotic lesions is the treatment of choice in symptomatic patients. An accurate preoperative evaluation is indispensable for therapeutic decisions mainly in the suspicion of intestinal wall and/or urinary tract infiltration, and also in cases where we need to establish histological diagnosis or to rule out malignant disease. Diagnostic tools, including transrectal ultrasound, magnetic resonance image, transvaginal ultrasound, barium enema, and colonoscopy, play significant roles in determining the presence, depth, histology, and other relevant data about the extension of the disease. Diagnostic algorithm depends on the clinical presentation, the expertise of the medical team, and the technology available at each institution. This article reviews and discusses relevant clinical points in endometriosis, including techniques and outcomes of the study of the disease through transrectal ultrasound and fine-needle aspiration.

Influência de dieta imunomoduladora na cicatrização cutânea em ratos / Influence of immunonutritional supplementation on skin wound healing in rats

INTRODUÇÃO: O processo de cicatrização é imediato e dinâmico, com o objetivo de restaurar a continuidade anatômica e funcional, e devem existir condições para esse processo, o que inclui um estado nutricional adequado. Dentre as fórmulas de suplementação existentes, as imunomoduladoras têm sido implicadas na melhora do processo cicatricial e das condições clínicas dos pacientes tratados. Foi avaliada a influência da dieta imunomoduladora (Impact®) sobre diferentes variáveis do processo de cicatrização cutânea. MÉTODO: Ratos adultos e nutridos foram divididos aleatoriamente em quatro grupos, a serem suplementados com a dieta em estudo e com a dieta controle. Dois grupos receberam as respectivas dietas apenas pré-operatoriamente e os outros dois grupos as receberam no perioperatório. Os ratos foram submetidos a três tipos de lesões cutâneas. Foram avaliados os seguintes aspectos: evolução dos pesos, evolução das áreas cruentas, tensiometria das feridas incisionais, taxas de reepitelização e parâmetros histológicos. RESULTADOS: Não houve diferença na evolução dos pesos. Houve melhores índices de fechamento de feridas excisionais nos grupos suplementados com Impact®, a partir do quinto dia de pós-operatório (p=0,02). Os grupos suplementados com a dieta em estudo obtiveram melhores resultados em tensiometria (p = 0,03), taxas de reepitelização (0,04), contagem diferencial de células (p<0,001) e quantidade de colágeno total (p<0,001). CONCLUSÕES: A dieta em estudo (Impact®) promove melhores taxas de fechamento de feridas cruentas, reepitelização mais rápida, cicatrizes com maior resistência tênsil e maiores quantidades de colágeno total nas feridas. Não houve diferença em nenhum dos parâmetros analisados em comparação dos grupos suplementados com Impact® pré e perioperatoriamente.

INTRODUCTION: The wound healing process is immediate and dynamic in order to restore anatomical and functional continuity, and there must be conditions for this process, which include a normal nutritional state. Among the existing supplemental formulas, immuno-enhancing diets have been proposed to improve the wound healing process and patients' clinical conditions. The influence of an immunomodulating diet (Impact®) on different variables of the skin healing process was evaluated. METHOD: Healthy adult rats were randomly divided into four groups of diet supplementation or control. Two groups received their diets only pre-operatively while the other two groups received theirs perioperatively. Rats were subjected to three types of skin lesions. We evaluated the following aspects: changes in weight, development of raw areas, tensiometry of incisional wounds, re-epithelialization rates, and histological parameters. RESULTS: There was no difference in weight changes. There was better closing rates of excisional wounds in groups supplemented with Impact® beginning on the fifth day after surgery (p = 0.02). The groups receiving the dietary supplements obtained the best results in tensiometry (p = 0.03), re-epithelialization rates (p = 0.04), differential cell counts (p < 0.001), and total amount of collagen (p < 0.001). CONCLUSIONS: The study diet (Impact®) promoted better closure rates of raw wounds, faster re-epithelialization, scars with a greater tensile strength, and greater amounts of total collagen in wounds. There was no difference in any of the parameters analyzed compared with the groups supplemented with Impact® pre- and perioperatively.

[Hepatitis C recurrence after living donor and cadaveric liver transplantation]. / Recurrência da Hepatite C após transplante hepático de doador vivo e falecido.

OBJECTIVE: To determine the recurrence of hepatitis C in patients subjected to living donor liver transplantation compared to those subjected to cadaveric liver transplantation. METHODS: Of a total of 333 liver transplantations, 279 (83.8%) were cadaveric liver transplantation and 54 (16.2%) living donor liver transplantation. Hepatic cirrhosis due to hepatitis C virus was the most common indication of both cadaveric liver transplantation (82 patients) and living donor liver transplantation (19 patients). The electronic study protocols of all patients with hepatic cirrhosis due to hepatitis C virus were reviewed. All data, including patients' age and sex, laboratory tests, hepatitis C virus recurrence and acute rejection were evaluated statistically. RESULTS: A total of 55 cadaveric liver transplantation and 10 living donor liver transplantation performed in patients with liver cirrhosis due to hepatitis C virus was included in the study. Clinical and laboratory characteristics of the two groups before the transplantation were similar, except for the prothrombin time that was higher for the cadaveric liver transplantation than the living donor liver transplantation (P = 0.04). Hepatitis C virus recurrence was similar in the cadaveric liver transplantation (n = 37; 69.3%) and living donor liver transplantation (n = 7; 70%) groups (P = 0.8). The incidence of acute rejection was similar in cadaveric liver transplantation (n = 27; 49%) and living donor liver transplantation (n = 2; 20%) groups (P = 0.08). Hepatitis C virus recurrence in patients of the cadaveric liver transplantation group who received bolus doses of corticosteroids (9 of 11 patients) was similar to the remained patients (28 of 44 patients) (P = 0.25). Recurrence was also similar in patients of the living donor liver transplantation group who received bolus doses of corticosteroids (one of one patient) in relation to those who did not receive them (six of nine patients) (P = 0.7). CONCLUSION: Hepatitis C recurrence is similar in patients who underwent living donor liver transplantation or cadaveric liver transplantation.

Donor complications including the report of one death in right-lobe living-donor liver transplantation.

BACKGROUND/AIMS: Our objective is to assess donor complications in all right hepatic lobe living-donor liver transplantation (LDLT) at our center. METHODS: Of a total of 352 liver transplantations performed, 60 were right-lobe LDLT. Most donors (88.3%) were related to the recipients. RESULTS: Mean hospital stay was 5.4+/-0.6 days. No complications occurred due to preoperative evaluation. Most donors received one or two units of autologous blood transfusion. Only 5 (8.3%) needed nonautologous blood transfusion. Most complications were minor and treated conservatively. Bile leaks from the cut surface of the liver occurred in 5 donors (8.3%). Two patients had potentially fatal complications: perforated duodenal ulcer and portal vein thrombosis (PVT). The donor with perforated ulcer developed septicemia and multiple organ failure. He was discharged from the hospital with hemiparesis due to cerebral ischemia. The patient with PVT remained asymptomatic and the portal vein was recanalized by the 3rd postoperative month. One donor died in the immediate postoperative period of cardiac arrest due to cardiac arrhythmia. CONCLUSION: Right hepatectomy for LDLT may be associated with significant morbidity, including death and it should be performed only by surgeons with great experience.

Recurrência da hepatite C após transplante hepático de doador vivo e falecido / Hepatitis C recurrence after living donor and cadaveric liver transplantation

OBJETIVO: Determinar a recurrência da hepatite C em pacientes submetidos a transplante hepático de doador vivo comparados com os submetidos a transplante hepático de doador falecido. MÉTODOS: Do total de 333 transplantes hepáticos, 279 (83,8 por cento) eram de doador falecido e 54 (16,2 por cento) de doador vivo. Hepatopatia crônica pelo vírus da hepatite C foi a indicação mais comum tanto de transplante hepático de doador falecido (82 pacientes) como de doador vivo (19 pacientes). O protocolo de estudo eletrônico de todos pacientes com hepatopatia crônica pelo vírus da hepatite C foi avaliado. Os dados coletados foram analisados estatisticamente conforme a idade, sexo, resultado dos exames laboratoriais, recidiva do vírus da hepatite C e rejeição aguda. RESULTADOS: O total de 55 transplantes hepáticos de doador falecido e 10 de doador vivo realizados em pacientes com cirrose hepática pelo vírus da hepatite C, foi incluído no estudo. As características clínicas e laboratoriais pré-transplante dos dois grupos foram similares, exceto o tempo de atividade de protrombina que foi maior no grupo de transplante hepático de doador falecido do que no de doador vivo (P = 0,04). A recidiva da hepatite C foi similar nos grupos de transplante hepático de doador falecido (n = 37; 69,3 por cento) e de doador vivo (n = 7; 70 por cento) (P = 0,8). A incidência de rejeição aguda foi igual no grupo de transplante hepático de doador falecido (n = 27; 49 por cento) e no grupo de doador vivo (n = 2; 20 por cento) (P = 0,08). A recurrência do vírus da hepatite C nos pacientes do grupo de transplante hepático de doador falecido que receberam pulsoterapia (9 de 11 pacientes) foi similar aos demais pacientes (28 de 44 pacientes) (P = 0,25). A recurrência também foi similar nos pacientes do grupo de transplante hepático de doador vivo que receberam pulsoterapia (1 de 1 paciente) em relação aos que não receberam (6 de 9 pacientes) (P = 0,7). CONCLUSÕES: A recurrência...

OBJECTIVE: To determine the recurrence of hepatitis C in patients subjected to living donor liver transplantation compared to those subjected to cadaveric liver transplantation. METHODS: Of a total of 333 liver transplantations, 279 (83.8 percent) were cadaveric liver transplantation and 54 (16.2 percent) living donor liver transplantation. Hepatic cirrhosis due to hepatitis C virus was the most common indication of both cadaveric liver transplantation (82 patients) and living donor liver transplantation (19 patients). The electronic study protocols of all patients with hepatic cirrhosis due to hepatitis C virus were reviewed. All data, including patients' age and sex, laboratory tests, hepatitis C virus recurrence and acute rejection were evaluated statistically. RESULTS: A total of 55 cadaveric liver transplantation and 10 living donor liver transplantation performed in patients with liver cirrhosis due to hepatitis C virus was included in the study. Clinical and laboratory characteristics of the two groups before the transplantation were similar, except for the prothrombin time that was higher for the cadaveric liver transplantation than the living donor liver transplantation (P = 0.04). Hepatitis C virus recurrence was similar in the cadaveric liver transplantation (n = 37; 69.3 percent) and living donor liver transplantation (n = 7; 70 percent) groups (P = 0.8). The incidence of acute rejection was similar in cadaveric liver transplantation (n = 27; 49 percent) and living donor liver transplantation (n = 2; 20 percent) groups (P = 0.08). Hepatitis C virus recurrence in patients of the cadaveric liver transplantation group who received bolus doses of corticosteroids (9 of 11 patients) was similar to the remained patients (28 of 44 patients) (P = 0.25). Recurrence was also similar in patients of the living donor liver transplantation group who received bolus doses of corticosteroids (one of one patient) in relation to those who did...

Análise da margem cirúrgica proximal do estômago em pacientes submetidos à gastrectomia subtotal por adenocarcinoma / Proximal gastric margin analysis following subtotal gastrectomy for adenocarcinoma

RACIONAL: A gastrectomia subtotal atualmente é considerada padrão ouro no tratamento da neoplasia gástrica do terço médio e distal. No entanto, foi demonstrado que a ocorrência de neoplasia residual na margem cirúrgica proximal está associada à redução da sobrevida. OBJETIVOS: analisar a margem cirúrgica proximal no exame anátomo-patológico de pacientes submetidos à gastrectomia subtotal por adenocarcinoma gástrico e identificar os fatores relacionados com o acometimento neoplásico dessa margem. MÉTODOS: No período entre janeiro de 1998 e dezembro de 2007 foram revisados os prontuários dos pacientes submetidos à gastrectomia subtotal devido a adenocarcinoma gástrico do terço médio e distal. Os pacientes foram analisados quanto à idade, sexo, classificação de Lauren, classificação de Borrmann, maior diâmetro da lesão, localização da lesão no estômago, clínico e presença de invasão angiolinfática. Foi realizada análise univariada desses dados em relação ao acometimento da margem proximal do estômago no exame anátomo-patológico. RESULTADOS: Foram analisados 104 casos: 34 do sexo feminino e 70 do sexo masculino com idade média de 57±13 anos. Doze pacientes (12,3 por cento) apresentaram acometimento da margem proximal. A análise univariada entre os fatores analisados e o acometimento neoplásico da margem proximal demonstrou associação somente em relação à classificação de Borrmann. CONCLUSÃO: A classificação macroscópica de Borrmann, especialmente nos estágios III e IV, está relacionada à presença de acometimento da margem proximal nos casos de adenocarcinoma gástrico dos terços médio e distal submetidos a tratamento com gastrectomia subtotal.

BACKGROUND: Subtotal gastrectomy is considered the gold standard treatment for gastric neoplasms localized in the distal and medial thirds of the stomach. Nevertheless, it has been shown that residual neoplasm into the proximal margin is associated to worse prognosis. AIM: To identify factors related to residual neoplasm into the proximal margin determined on pathology examination of patients subjected(Submitted) to subtotal gastrectomy for gastric adenocarcinoma. METHODS: The charts of the patients subjected(Submitted) to subtotal gastrectomy due to gastric adenocarcinoma of the distal and medial thirds were reviewed from January 1998 to December 2007. It was recorded data referred to age, sex, Lauren and Borrmann staging, neoplasm diameter, localization inside the stomach, TNM staging and angiolymphatic invasion. These data were submitted to univariate analysis in relation to residual neoplasm into the proximal margin. RESULTS: A hundread and four cases were included: 34 females and 70 males. The median age was 57±13 years. Twelve patients (12.3 percent) presented residual neoplasm into the proximal margin. The univariate analysis showed association between only the Borrmann staging and the residual neoplasm. CONCLUSION: Borrmann staging is associated to residual neoplasm into the proximal margin in patients subjected(Submitted) to subtotal gastrectomy for medial and distal thirds gastric adenocarcinoma.

Linfadenocromatografia perigástrica com carbono ativado (CH40): estudo experimental / Perigastric lymphadenochromatography with activated carbon (CH40): experimental study

RACIONAL: Procedimento cirúrgico bem instituído e planejado constitui ainda a única terapêutica efetiva para o câncer gástrico. Entretanto, os resultados de cura não têm melhorado significativamente nas últimas décadas, principalmente no ocidente. O principal benefício de introdução endoscópica de corantes na submucosa gástrica está na facilitação de linfadenectomias regradas, podendo facilitar a localização acurada dos linfonodos. Além disso, a linfadenocromatografia possibilita futuras pesquisas para a detecção do linfonodo sentinela e sua aplicabilidade racional e seletiva na indicação precisa da linfadenectomia, principalmente dos grupos de linfonodos de ressecção mais trabalhosa e com maiores possibilidades de complicações. A linfadenocromatografia com carbono ativado (CH40) foi analisada neste estudo experimental (fase 1). OBJETIVOS: Testar a efetividade e inocuidade da linfadenocromatografia com CH40, em três espécies animais diferentes. MÉTODOS: Como preconizado pela Associação Brasileira de Pesquisas Clínicas (Resoluções nº 196/96 e 251/97, CNS/MS), foram utilizados três espécies diferentes de animais: 3 cães, 10 coelhos e 20 ratos. Em todos os cães, a introdução de CH40 na camada submucosa de estômago foi realizada através da endoscopia gástrica e utilizando, cateter de polietileno agulhado, usualmente empregado na esclerose de varizes esofageanas. O período de observação variou de 43 a 125 dias, quando o procedimento cirúrgico foi realizado. Em todos os coelhos e ratos a introdução de CH40 foi realizada através de agulha hipodérmica e seringa insulínica, na região subcutânea inguinal. O período de observação foi de 102 a 105 dias e 110 a 122 dias, respectivamente. RESULTADOS: Nos períodos de observação, desde a injeção até a eutanásia, não se detectou em nenhum animal efeito colateral ou óbito. Nos cães, linfonodos perigástricos foram corados pelo CH40. Em todos os coelhos e ratos, o tecido celular subcutâneo da região inguinal foi fortemente corado de preto. Também, em todos ratos, linfonodos da região aórtica abdominal foram tingidos pelo CH40. CONCLUSÃO: A linfadenocromatografia com CH40 não mostrou toxicidade nas três espécies de animais estudadas. O carbono ativado foi efetivo no tingimento de linfonodos neste estudo.

BACKGROUND: Well instituted and planned surgical procedures are still the only effective therapy for gastric cancer. However, results of cure have not significantly improved in the last decades, especially in the western world. The main benefit of the introduction of dyes and colouring in gastric submucosa through endoscopy, is to facilitate moderate lymphadectomy, making it easier to accurately locate lymph nodes. Besides this, lymphadenochromatography makes future research possible in detecting sentinel lymph nodes and its rational and selective applicability in precise lymphadectomy indication, especially in groups submitted to more complicated lymph node ressection which have increased possibility of complications. Carbon actived (CH40) lymphadenochromatography was analysed in this experimental study (phase 1). AIM: To test the effectiveness and innocuity of lymphadenochromatography with CH40, in three different animal species. METHODS: As established by the Brazilian Association of Clinical Research (Resolutions nº 196/96 e 251/97, CNS/MS), three different animal species were used: three dogs, 10 rabbits and 20 rats. In all of the dogs, the introduction of CH40 in the submucosa layer of the stomach was performed using gastric endoscopy, as well as needle polyethylene catheters, usually employed in sclerosis of esophageal varicosis. The observation period varied between 43 to 125 days, when surgical procedures were performed. In all rabbits and rats, the introduction of CH40 was made through hypodermic needle and insulinic syringe in the subcutaneous inguinal region. The observation period was between 102 through 105 days and 110 to 122 days, respectively. RESULTS: During the observation periods, from injection to euthanasia, no side effects or death was detected in any animal. In the dogs, perigastric lymph nodes were dyed using CH40. In all rabbits and rats, the subcutaneous cellular tissue of the inguinal region was dyed black strongly. Also, in all rats, lymph nodes of the abdominal aortic region were colored using CH40. CONCLUSIONS: Lymphadenochromatography with CH40 did not demonstrate toxicity in the three animal species studied. Actived carbon was effective in the coloring of lymph nodes in this study.

Linfadenocromatografia perigástrica com carbono ativado (CH40): estudo clínico / Perigastric lymphadenochromatography with activated carbon (CH40): clinical study

RACIONAL: Operação bem instituída e planejada constitui ainda a única terapêutica efetiva para o câncer gástrico, porém os resultados de cura não têm melhorado significativamente nas últimas quatro décadas, principalmente no mundo ocidental. O principal benefício de introdução endoscópica de corantes na submucosa gástrica está na facilitação de linfadenectomias regradas, podendo auxiliar a localização acurada das cadeias linfonodais. Além disso, a linfadenocromatografia possibilita futuras pesquisas para a detecção do linfonodo sentinela e sua aplicabilidade racional e seletiva na indicação precisa da linfadenectomia, principalmente dos grupos de linfonodos de ressecção mais trabalhosa e com maiores possibilidades de complicações. A linfadenocromatografia perigástrica com carbono ativado (CH40) no câncer gástrico foi analisada neste estudo clínico (fase 2). OBJETIVOS: 1) Determinar a percentagem de linfonodos corados após injeção endoscópica de CH40 na camada submucosa do estômago peritumoral; 2) determinar a percentagem dos linfonodos perigástricos corados pelo CH40 com metástases; 3) avaliar a coloração linfonodal com CH40 como marcador de metástase tumoral. MÉTODOS: Dez pacientes com câncer gástrico, em diversos estádios, foram avaliados. Carbono ativado (CH40) foi introduzido por via endoscópica no pré-operatório, na camada submucosa do estômago, na região peritumoral. Todos os pacientes foram operados e os grupos de linfonodos das diversas cadeias perigástricas foram dissecados e ressecados, isolados no pós-operatório imediato e separados, conforme agrupamento estabelecido conceitualmente pela Sociedade Japonesa de Pesquisa em Câncer. RESULTADOS: A idade variou de 50 a 68 anos, com média de 58,9 anos. Foram incluídos quatro pacientes do sexo feminino e seis do masculino. Foram ressecados 481 linfonodos, média de 48,1 linfonodos por operação. Foram corados 368 (76,50%) linfonodos, não sendo corados 113 (23,50%). Linfonodos perigástricos com metástases foram 68, sendo 51 (75,00%) corados e 17 (25,00%) não corados pelo CH40. CONCLUSÕES: Linfadenocromatografia com CH40 não se apresentou como marcador eficiente de metástase tumoral.

BACKGROUND: The well-instituted and planned surgery is the unique effective treatment for gastric cancer. However, in the last four decades, we haven´t seen significant improvements in the cure results, specially in the Ocident. The ink injection is realized for the best identification of lymph node groups. The principal benefit of endoscopic gastric submucosal ink injections is for the lymphadenectomies, where it can facilitate the accurate lymph node localization. Moreover, sentinel lymph node researches can be done using the lymphadenochromatography, with the purpose of racional and selective application of lymphadenectomy, principally in the more difficult lymph node group resections, minimizing complications. The perigastric lymphadenochromatography with activated carbon (CH40) has been studied in this clinical study (phase 2). AIM: 1) To determine the percentage of lymph node stained after endoscopic injection of CH40 in the peritumoral gastric submucosa; 2) to determine the percentage of perigastric lymph node with metastasis stained by CH40; 3) to evaluate the lymph node staining with CH40 as a metastatic marker. METHODS: Ten patients, with different gastric cancer stages, were prospectively studied. Diagnosis of gastric cancer was performed by upper digestive endoscopy with biopsies and pathological analysis. Preoperative injection of CH40 in the peritumoral gastric submucosa was performed. All patients were operated and the lymph node groups, from the different perigastric lymph node chains, were dissected and resected. They were separated according to the Japanese Gastric Cancer Association (JGCA) concepts. RESULTS: The age varied from 50 to 68, average of 58,9. Six were male and four female patients. 481 lymph nodes were ressected, with the average of 48,1 for each surgery. There were 368 stained lymph nodes (76,5%) and 113 (23,5%) without staining. Perigastric lymph nodes with metastasis were stained by CH40 in 75% (51 from 68). However, 25% (17 from 68) of metastatic lymph nodes had no ink. CONCLUSIONS: The lymphadenochromatograhy with CH40 was not an efficient metastatic marker in this study. In this phase 2 clinical study there was no stratification of stages.

Seleção e uso de antibióticos em infecções intra-abdominais / Selection and use of anti-infective agents for intra-abdominal infections

RACIONAL: Infecções intra-abdominais são comuns e apresentam elevada morbidade e mortalidade e os agentes infecciosos responsáveis por tais afecções são geralmente os da flora gastrointestinal, em especial a E. coli e Bacteroides fragilis. OBJETIVO: Apresentar uma revisão da seleção e uso de antibióticos em infecções intra-abdominais. CONCLUSÕES: O uso adequado de antibióticos é fundamental para o controle mais rápido da infecção e reduzir a possibilidade de falha no tratamento. A terapia antimicrobiana é iniciada na suspeita de infecção intra-abdominal e os agentes antibióticos selecionados são utilizados de acordo com os germes mais prováveis de serem encontrados no local da infecção. Além disso, eficácia, custo, segurança e comodidade posológica são considerados para uma seleção mais apropriada. Diferentes esquemas são utilizados em infecções intra-abdominais comunitárias e hospitalares devido à flora mais resistente destas últimas.

BACKGROUND: Intra-abdominal infections are common and are associated with elevated morbidity and mortality. The microorganisms that cause intra-abdominal infections are usually from the gastrointestinal flora, mainly E. coli and Bacteroides fragilis. AIM: To present a review of the selection and use of antibiotics in intra-abdominal infections. CONCLUSIONS: Appropriate use of antibiotics is essential to control infection and to reduce treatment failure. Antibiotics are initiated whenever intra-abdominal infection is suspected and the antimicrobial agents are selected based on the most common microorganisms involved. In addition, efficacy, cost, safety, and posologic regimen are considered for an appropriated selection. Antibiotic regimen is different whether the infection is acquired in the community or at hospital due to the more resistant flora in the latter.

Intussuscepção, oclusão e perfuração jejunal na síndrome de Peutz-Jeghers: relato de caso / Jejunal intussusception, occlusion and perforation in the Peutz-Jeghers syndrome: case report

Racional - a síndrome de Peutz-Jeghers é um distúrbio hereditário autossômico dominante caracterizado por pólipos hamartomatoses intestinais associados a máculas melanocíticas cutaneomucosas e que frequentemente requerem intervenções cirúrgicas para tratamento de suas principais complicações (oclusão, perfuração e sangramento). Relato de caso - adolescente masculino de 17 anos com história anterior de intussuscepção, episódios repetidos de sub-oclusão intestinal e emagrecimento de aproximadamente 10 kg nos últimos quatro meses / Background - the Peutz-Jegher's sndrome is an autosomal dominant inherited disorder characterized by hamartomatous gastrointestinal polyps and mucocutaneous pigmentation. This syndrome usually requires surgical treatment for its complications. Case report - a 17 years old patient with previous history of intussusception, intestinal sub-oclusion and weight lost of 10 kg in the last four months was admitted to the hospital...