Alberto Goldenberg

Role of EUS in the preoperative localization of insulinomas compared with spiral CT

BACKGROUND Preoperative radiologic localization of insulinomas often fails because of the small size of these tumors. Endoscopic ultrasound (EUS) can localize insulinomas in up to 80% of the cases. The aim of this study was to compare EUS and computed tomography (CT) diagnostic accuracy for insulinomas. METHODS We reviewed medical records from 12 patients (10 women) with a biochemical diagnosis of hypoglycemia and hyperinsulinism from 1 university hospital and 1 community hospital. A diagnosis of insulinoma was ultimately made in all cases and before surgery the patients underwent abdominal US, spiral CT and EUS in an attempt to precisely localize the tumor. Surgery was considered the standard for tumor localization. RESULTS Ten tumors were benign (83.3%) and 2 were malignant (16.7%). The overall sensitivity of EUS in identifying insulinomas was 83.3% compared with 16.7% for CT. Tumors not detected by EUS had a mean size of 0.75 cm. EUS-guided fine-needle aspiration was possible in only 3 patients, with a positive cytologic diagnosis in 2 (66.6%). Tumors located in the head and body of the pancreas were identified by EUS in all patients, but those located in the tail were diagnosed in only 50% of the cases. CONCLUSIONS EUS is superior to spiral CT and should replace it for the detection of pancreatic insulinomas. EUS identification depends on the site and size of the tumor.

Comparative study of inflammatory response and adhesions formation after fixation of different meshes for inguinal hernia repair in rabbits

OBJETIVO: Avaliar a resposta inflamatoria e a formacao de aderencias das proteses de polipropileno e polipropileno associado a poliglactina sintetica (Vypro®) implantadas no espaco pre-peritoneal de coelhos. METODOS: Foram utilizados 14 coelhos albinos linhagem Nova Zelândia com tres meses de idade, machos com peso variando de 2000 a 2500 gramas. O acesso a cavidade se deu por incisao mediana abaixo do apendice xifoide com oito centimetros de extensao. Realizou-se o implante da tela de polipropileno no flanco esquerdo com um ponto de polipropileno em cada extremidade da protese. No flanco direito a tela Vypro® foi fixada da mesma forma com pontos de polipropileno. A laparoscopia foi realizada 28 dias apos o primeiro procedimento para avaliacao de aderencias intracavitarias. As proteses juntamente com o peritonio, musculatura e aponeurose adjacente foram retiradas em blocos individuais. Cada peca foi imersa em solucao tamponada de formaldeido a 10% e encaminhada ao patologista. RESULTADOS: Todos os animais tiveram boa evolucao pos-operatoria nao havendo infeccao das incisoes cirurgicas ou obito dos coelhos. Das quatorze proteses Prolene implantadas no peritonio intacto de coelho, em onze (78,6%) houve formacao de aderencias Das quatorze proteses Vypro®implantadas no peritonio intacto de coelho, em doze (85,7%) houve formacao de aderencias. Comparando as duas proteses entre si nao houve diferenca significante quanto ao numero de aderencias formadas. Em relacao a avaliacao microscopica, nas proteses VYPRO® a reacao granulomatosa do tipo corpo estranho e a fibrose foram predominantemente moderadas. Ja a inflamacao inespecifica foi proporcionalmente leve e moderada A inflamacao inespecifica foi menos intensa nas proteses de polipropileno. CONCLUSAO: Ambas as proteses implantadas na cavidade peritoneal de coelhos promovem a formacao de aderencias de forma semelhante. As proteses de polipropileno e associado a poliglactina promovem maior fibrose, apresentando melhor incorporacao aos tecidos.PURPOSE Compare, in a rabbit model, the inflammatory response and adhesions formation following surgical fixation of polypropilene and Vypro mesh in the inguinal preperitoneal space. METHODS Fourteen male New Zealand rabbits, weighing between 2.000 to 2.500 g were used. A midline incision was made and the peritoneal cavity was exposed. The 2.0 x 1.0 cm polypropylene mesh was fixed in the left flank and secured to the margins with 3-0 prolene in a separate pattern. In the right flank, a 2.0 x 1.0 cm Vypro II mesh was sewn in the same way. After the post surgical period, the animals were again anesthetized and underwent laparoscopic approach, in order to identify and evaluate adhesions degree. Both fixed prosthesis were excised bilaterally with the abdominal wall segment, including peritoneum, aponeurosis and muscle and sent to a pathologist. RESULTS Operative time ranged from 15 to 25 minutes and no difficulties in applying the mesh were found. From the 14 polypropylene meshes fixed to the intact peritoneum, 11 had adhesions to the abdominal cavity (78.6%). Concerning Vypro mesh, 12 animals developed adhesions from the 14 with mesh fixation (85.7%). Histological examination of tissues harvested revealed fibroblasts, collagen, macrophages and lymphocytes between the threads of the mesh. CONCLUSION Polypropylene and Vypro mesh, when implanted in the peritoneal cavity of rabbits provoke similar amount of adhesions. Vypro mesh tissues had higher fibrosis resulting in better mesh incorporation to the abdominal wall.

Assessment of staging, prognosis and mortality of colorectal cancer by tumor markers: receptor erbB-2 and cadherins

PURPOSE To evaluate the prognostic significance and correlation with staging and degree of cell differentiation of the tumoral expression of the proteins c-erbB-2 and E-cadherin, in patients with colorectal adenocarcinoma. METHODS The study included 117 patients with an average age of 63.1 years and an average follow-up duration of 28.1 months. The disease-free interval, survival, incidence of recurrence and specific mortality were evaluated. c-erbB-2 anti-oncoprotein antibodies (Dako) were utilized via the streptavidin-biotin technique. Samples were considered to be positive for c-erbB-2 if 10% or more of the tumor cell membranes were stained. The anti-E-cadherin antibodies (Dako), evaluated this protein and is considered positive, if 50% or more of the cell membranes were stained. Statistical analysis was performed using Pearsons chi-squared test, Fishers exact test, Kaplan-Meiers estimator, the log-rank test and Wilcoxons test (Breslow version), setting the level of statistical significance at 5% (p<0.05). RESULTS 52 of 108 patients studied for c-erbB-2 were positive (48.1%), 47 of 93 patients studied for E-cadherin were negative (50.5%). These data do not express any correlation with TNM (tumor, node and metastasis) staging and the degree of cell differentiation or with the tumor recurrence rate. The disease-free interval among patients who were positive for c-erbB-2 and negative for E-cadherin was 68.0 months and did not differ from those with c-erbB-2 negative and E-cadherin positive (55.0 months--p = 0.5510). The average survival among patients positive for c-erbB-2 and negative for E-cadherin was 75 months without statistical significance difference with the other group (61 months--p = 0.5256). Specific mortality occurred in 20.0% of the cases and did not correlate with the expression of c-erbB-2 (p=0.446), E-cadherin (p=0.883). CONCLUSION The tumoral expression of c-erbB-2 and E-cadherin did not demonstrate a correlation with the staging and degree of cell differentiation, and it did not present prognostic value regarding disease recurrence, disease-free interval, survival and specific mortality among patients with colorectal adenocarcinoma.

New Trends in Diffusion-Weighted Magnetic Resonance Imaging as a Tool in Differentiation of Serous Cystadenoma and Mucinous Cystic Tumor: A Prospective Study

Background/Aims: Pancreatic cystic lesions are increasingly being recognized. Magnetic resonance imaging (MRI) is the method that brings the greatest amount of information about the morphologic features of pancreatic cystic lesions. To establish if diffusion-weighted MRI (DW-MRI) can be used as a tool to differentiate mucinous from nonmucinous lesions. Methods: Fifty-six patients with pancreatic cystic lesions (benign, n = 46; malignant, n = 10) were prospectively evaluated with DW-MRI in order to differentiate mucinous from nonmucinous lesions. Final diagnosis was obtained by follow-up (n = 31), surgery (n = 16) or endoscopic ultrasound-guided fine needle aspiration (n = 9). Serous cystadenoma was identified in 32 (57%) patients. Results: The threshold value established for the differentiation of mucinous from nonmucinous lesions was 2,230.06 s/mm2 for ADC of 700. DWI-MRI behavior between mucinous and nonmucinous groups revealed sensitivity, specificity, positive predictive value, negative predictive value and accuracy to be 80, 98, 92, 93 and 93%, respectively (p < 0.01, power of sample = 1.0). In the comparison of the diffusion behavior between mucinous (n = 13) and serous (n = 32) lesions, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100, 97, 92, 100 and 98%, respectively (p < 0.01, power of sample = 1.0). The results of endoscopic ultrasound-guided fine needle aspiration were similar to those of DW-MRI. Conclusions: DW-MRI can be included as part of the array of tools to differentiate mucinous from nonmucinous lesions and can help in the management of pancreatic cystic lesions.

Effects of the polypropylene mesh implanted through inguinotomy in the spermatic funiculus, epididium and testis of dogs

PURPOSE To investigate the effects of polypropylene mesh, implanted by inguinotomy, in the spermatic funiculus, epididium and testis of dogs. METHODS Eighteen dogs were considered (12-23 Kg), separated in three groups. Group A (n=7): left side (with mesh) versus right side (without mesh); Group B (n=7): left side (without mesh) versus right side (with mesh) and Group C (n=4): without any surgical manipulation (control group). After being observed for 60 days, the animals were subjected to bilateral removal of the spermatic funiculus, epididium and testis that were submitted to histological analysis. During the re-operation, a macroscopic evaluation was performed. RESULTS On the mesh side, we noted 100% of mesh adherence to the posterior wall of the inguinal canal, as well as the adherence of the spermatic funiculus to the mesh. A congestion of the pampiniform plexus was noted in three animals. Chronic inflammation reaction and foreign body reaction in the spermatic funiculus was observed in 100% of the animals. On the side that did not carry a mesh, chronic inflammatory reaction was observed in 71% of the animals. All the animals presented chronic inflammatory reaction in the deferent duct in the mesh side and in eleven animals in the side without the mesh. These alterations were not found in Group C. There was a considerable statistical reduction in the average difference of the diameter of the lumen of the deferent duct in the mesh side. In the epididium and testis, macro and microscopic alterations were not significant, although one animal presented a marked reduction of spermatogenesis on the mesh side. CONCLUSION The polypropylene mesh, when in contact with the spermatic funiculus of dogs, causes a more intense chronic inflammatory reaction and a significant reduction in the diameter of the lumen of the deferent duct.

SOLID PSEUDOPAPILLARY NEOPLASM OF THE PANCREAS

ABSTRACT Background: The solid pseudopapillary neoplasm is a rare tumor of the pancreas. However, it´s etiology still maintain discussions. Aim: To analyze it´s clinical data, diagnosis and treatment. Methods: A retrospective study of medical records of all patients treated from January 1997 until July 2015. Results: Were identified 17 cases. Most patients were women (94.11%) and the average age was 32.88 years. The main complaint was abdominal mass (47.05%). The most frequent location was in the body/tail of the pancreas (72.22%) and the most frequently performed surgery was distal pancreatectomy with splenectomy (64.70%). No patient had metastases at diagnosis. Conservative surgery for pancreatic parenchyma was performed in only three cases. The rate of complications in the postoperative period was 35.29% and the main complication was pancreatic fistula (29.41%). No patient underwent adjuvant treatment. Conclusions: The treatment is surgical and the most common clinical presentation is abdominal mass. Distal pancreatectomy with splenectomy was the most frequently performed surgery for its treatment.

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation

PURPOSE Evaluate short results after fundoplication procedure, concerning the division of short gastric vessels. METHODS A prospective randomization of 90 patients with indication for hiatoplasty and total fundoplication with fundus mobilization was performed. They were divided into two groups: no SGV division (group A, n= 46) and with SGV division (Group B, n=44), although in both groups the gastric fundus was mobilized to perform a floppy valve. Early outcome with clinical follow up (1 year) was observed. RESULTS Both groups were similar regarding preoperative parameters and severity of gastroesophageal reflux disease (GERD). No difference in morbidity was observed during hospital stay. Nevertheless, the median operating time was 80,2 minutes in group A and 94,1 minutes (p=0,021) in Group B. Transitory dysphagia during the first year was significantly lower in group B (46,6% versus 23,2%, p=0,012). However, in 12 months clinical outcome was similar in both groups (clinical symptoms of GERD, persistent dysphagia and reoperations). CONCLUSION There was no improvement in routine division of SGV in total fundoplication procedure when the gastric fundus was mobilized.

Analysis of the correlation between p53 and bcl-2 expression with staging and prognosis of the colorectal adenocarcinoma

PURPOSE To analyze the correlation between p53 and bcl-2 expression and colorectal adenocarcinoma staging and prognosis. METHODS This was a retrospective series of 125 colorectal adenocarcinoma patients (67 women and 58 men; ages 30-87 years) who underwent surgery with curative intent. The mean follow-up was 28.5 months (range: 2-96 months). TNM staging, tumor recurrence, survival and cancer-related mortality were analyzed. Immunoreactivity was evaluated using DO7 (Dako) for p53 and K492 (Dako) for bcl-2. Tumors with accumulation of staining for cytoplasmic bcl-2 or nuclear p53 in more than 10% of cells were considered positive. Statistical analysis utilized Pearson chi-squared, log-rank and Wilcoxon tests, and Kaplan-Meier survival estimation (significance level: p<0.05). RESULTS p53+ was found in 11.8% (14/118), bcl-2+ in 50% (58/116) and associated p53+/bcl-2+ in 6.4% (7/109) of the tumors. There was no significant correlation between expression of these biomarkers and TNM I, II, III and IV staging (p=0.385 for p53; p=0.461 for bcl-2). For tumor recurrence, p53+ was found in 9.5% (2/21), bcl-2+ in 50% (11/22), and associated p53+/bcl-2+ in 5.2% (1/19) of the tumors (p=0.714, p=1.000 and p=0.960, respectively). For survival analysis, p53+: 57 months (45.0-68.0), bcl-2+: 78 (37.0-89.0), and p53+/bcl-2+: 62 (56.0-68.0) (p=0.319). For cancer-related mortality, p53+: 8.3% (3/36), bcl-2+: 47.2% (17/36), and p53+/bcl-2+: 5.9% (2/36) of the patients (p=0.432, p=0.688 and p=0.907, respectively). CONCLUSION No correlation was found between tumor expression of p53 and bcl-2 and the TNM staging, recurrence, survival and cancer-related mortality in colorectal adenocarcinoma.

Prospective study on the effects of a polypropylene prosthesis on testicular volume and arterial flow in patients undergoing surgical correction for inguinal hernia

PURPOSE To evaluate testicular volume and arterial flow in patients undergoing surgical correction for inguinal hernia, with polypropylene prosthesis. METHODS This was an observational prospective clinical study on 39 male patients with unilateral inguinal hernia of types III A and III B according to the Nyhus classification who underwent surgical correction with implantation of a polypropylene prosthesis by means of the Lichtenstein technique. The patients were evaluated using Doppler ultrasound before the operation and selectively at the third and sixth months after the operation. The variables studied were testicular volume, systolic and diastolic velocity, resistance index and pulsatility index. RESULTS No statistically significant alterations in the variables studied were observed over the course of time: testicular volume (p= 0.197); systolic velocity (p= 0.257); diastolic velocity (p= 0.554); resistance index (p= 0.998); and pulsatility index (p= 0.582). CONCLUSION No alteration in testicular volume and arterial flow over a six-month period was observed among patients who underwent surgical correction for inguinal hernia using a polypropylene prosthesis.

Experimental model of gastroesophageal reflux in rats

PURPOSE To develop an experimental model of gastroesophageal reflux in rats. METHODS Sixty Wistar rats underwent surgery and were assigned to one of the three groups of twenty animals each. The animals in group A underwent total esophageal myectomy and, in group (B), underwent partial myectomy. The third group was the control group (C). A contrast radiographic study of the esophagus was performed to evaluate gastroesophageal reflux. The anatomopathological study of the esophagus was used to evaluate esophagitis. RESULTS During the 30-day postoperative follow-up, 14 animals in group A presented with reflux of barium in the esophagus. The presence of barium in the esophagus was observed in 7 animals in group B and in 2 animals in the control group. The result of the histopathology examination was controversial. A marked weight loss in the rats undergoing total myectomy was observed, however there was no significant statistical difference. CONCLUSION Total myectomy in the lower third of the esophagus caused gastroesophageal reflux in the majority of the animals.