Andy Petroianu

Modified therapy with 5-fluorouracil, doxorubicin, and methotrexate in advanced gastric cancer

Background. In an attempt to decrease the toxic effects of fluorouracil, doxorubicin, and methotrexate (FAMTX) by reducing the dose of methotrexate from 1500 mg/m2, according to the original regimen, to 1000 mg/m2, the authors designed the modified FAMTX treatment that was evaluated in a prospective Phase II‐III randomized trial.

Preferred reporting of case series in surgery; the PROCESS guidelines

INTRODUCTION Case series have been a long held tradition within the surgical literature and are still frequently published. Reporting guidelines can improve transparency and reporting quality. No guideline exists for reporting case series, and our recent systematic review highlights the fact that key data are being missed from such reports. Our objective was to develop reporting guidelines for surgical case series. METHODS A Delphi consensus exercise was conducted to determine items to include in the reporting guideline. Items included those identified from a previous systematic review on case series and those included in the SCARE Guidelines for case reports. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. Surgeons and others with expertise in the reporting of case series were invited to participate. In round one, participants voted to define case series and also what elements should be included in them. In round two, participants voted on what items to include in the PROCESS guideline using a nine-point Likert scale to assess agreement as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group. RESULTS In round one, there was a 49% (29/59) response rate. Following adjustment of the guideline with incorporation of recommended changes, round two commenced and there was an 81% (48/59) response rate. All but one of the items were approved by the participants and Likert scores 7-9 were awarded by >70% of respondents. The final guideline consists of an eight item checklist. CONCLUSION We present the PROCESS Guideline, consisting of an eight item checklist that will improve the reporting quality of surgical case series. We encourage authors, reviewers, editors, journals, publishers and the wider surgical and scholarly community to adopt these.

Functions of the splenic remnant after subtotal splenectomy for treatment of severe splenic injuries

BACKGROUND To evaluate the clinical and laboratory characteristics of patients submitted to subtotal splenectomy during the immediate and late postoperative period. METHODS The study was conducted on 34 patients, 25 of whom were submitted to subtotal splenectomy (group I), and 9 to total splenectomy without preservation of splenic tissue (group II), and on 22 patients with intact spleens (group III, control). The immediate and late postoperative complications were investigated. Hematological examinations were performed during the late postoperative period (red cell count, hemoglobin, platelets, total and segmented leukocytes, lymphocytes, and Howell-Jolly bodies). Immunoglobulins (IgA, IgM, and IgG) and total T lymphocytes (TTL), active T lymphocytes (ATL), and B lymphocytes were also determined. Splenic scintigraphy with (99m)Tc colloidal sulfur was performed. RESULTS Groups I and III did not presented abnormal blood bodies and their hematological and immunological pattern were normal. None of the groups showed leukocytosis or thrombocytosis. Howell-Jolly bodies were observed only in group II, which also showed reduced IgM levels. Scintigraphy showed filtering splenic tissue in group I. CONCLUSIONS We conclude that subtotal splenectomy is a good surgical alternative for serious distal spleen lesion or when the main splenic pedicle is injured.

Brazilian law for scientific use of animals

UNLABELLED The Brazilian scientific community claimed for a definitive systematization and for comprehensive and realistic national rules, to provide guidance and regulation, instead of sanctions, so that the question of scientific research involving animals could be better contemplated. This is beginning to occur now with Law no. 11.794, sanctioned by the President of the Republic on November 8, 2008. PURPOSE To describe the evolution of Brazilian regimentation for scientific use of animals and to analyze Law no. 11.794. METHODS The legislation about the use of animals in teaching and in scientific research in Brazil and in Rio de Janeiro State was identified and discussed. RESULTS Until now, there was no updated general and systematizing rule regarding animal vivisection and experimentation for didactic or scientific purposes. The only specific law dates back to 1979 and was not regimented. More recent laws equated the practice of scientific experiments to acts of abuse and mistreatment of animals, when alternative technology was available. Municipal laws that restricted the scientific practice of vivisection and experimentation with animals were created in the cities of Rio de Janeiro and Florianopolis. CONCLUSION With the claim and collaboration of the scientific community, the sanction of Law no. 11.794 regarding the scientific use of animals represented an invaluable advance in spite of the presence of some points that eventually may require another type of treatment. The new Law states that it will be regimented within 180 (one-hundred-and-eighty) days, when some of these points could be better elucidated.

Diagnosis of acute appendicitis

Appendicitis is the most common abdominal emergency. While the clinical diagnosis may be straightforward in patients who present with classic signs and symptoms, atypical presentations may result in diagnostic confusion and delay in treatment. Abdominal pain is the primary presenting complaint of patients with acute appendicitis. Nausea, vomiting, and anorexia occur in varying degrees. Abdominal examination reveals localised tenderness and muscular rigidity after localisation of the pain to the right iliac fossa. Laboratory data upon presentation usually reveal an elevated leukocytosis with a left shift. Measurement of C-reactive protein is most likely to be elevated. The advances in imaginology trend to diminish the false positive or negative diagnosis. Radiographic image of faecal loading image in the caecum has a sensitivity of 97% and a negative predictive value that is 98%. In experienced hands, ultrasound may have a sensitivity of 90% and specificity higher than 90%. Helical CT has reported a sensitivity that may reach 95% and specificity higher than 95%. Despite all medical advances, the diagnosis of acute appendicitis continues to be a medical challenge.

Subtotal splenectomy for treatment of severe splenic injuries.

OBJECTIVE The spleen is an organ of the defense system with important roles in filtering functions, phagocytosis, and immunoglobulin production. Septic phenomena are severe complications that may occur after total splenectomy. To avoid these adverse effects, the preservation of the spleen is indicated. However, in the presence of severe spleen damage, lesions of the splenic pedicle, or both, complete removal of the spleen has been considered unavoidable. METHODS The present paper presents the preservation of the upper splenic pole supplied by the splenogastric vessels in six patients with severe injuries of the spleen and its pedicle. RESULTS All patients had good postoperative courses. CONCLUSIONS Subtotal splenectomy may be useful in the treatment of severe injuries of the distal part of the spleen, when the vessels of its pedicle are damaged, or both.

Regeneration of splenic autotransplants.

Abstract. Splenic autotransplantation seems to be the only alternative for preservation of splenic tissue after total splenectomy. This work was carried out to analyze the morphologic regeneration of autotransplanted splenic tissue in Wistar rats and to determine the bacterial phagocytic function of their macrophages. We utilized an experimental model including young and adult rats, of both sexes, submitted to total splenectomy combined with autotransplantation in the greater omentum of slices of the whole mass of spleen. Sixteen weeks later animals were intravenously inoculated with a suspension of Escherichia coli AB1157. There was regeneration of autotransplanted splenic tissue in all animals. A similar morphological aspect among all animals was observed, with splenic tissue showing red and white pulps with a moderate architectural disarrangement. Macrophages containing bacterial aggregates were observed, as well as macrophages with hemosiderin pigments inside the cytoplasm. Blood vessels showed preserved walls, with no signs of vasculitis or thrombosis. The present results suggest that splenic autotransplants in the greater omentum of the rat acquire the macro- and microscopic architecture of a normal spleen, with reduced dimensions, and preserve bacterial phagocyte function.

Tratamento cirúrgico da hipertensão porta na esquistossomose mansoni

Portal hypertension is defined by an hepatic venous pressure gradient greater than 5mmHg. It is usually caused by an increase in resistance in the portal-hepatic vascular bed due to obstruction to flow. The severe forms of schistosomiasis usually evolve with portal hypertension, esophageal, intraabdominal, retroperitoneal and abdominal wall varices. Massive bleeding due to esophageal or gastric variceal rupture is the major complication of portal hypertension in schistosomiasis. In regard to treatment, clinical (propranolol, somatostain, octreotide), endoscopic (sclerotherapy, clips and ligature of varices), vascular (TIPS - transjugular intrahepatic portosystemic shunt) and surgical (portosystemic shunts and portovariceal disconnection) approaches have been tried to decrease portal hypertension and prevent bleeding. In the present review the author discusses the subject emphasizing the surgical procedures.

Autotransplantation for treatment of severe splenic lesions.

Abstract. The aim of the study was to evaluate clinical and laboratory variables in patients undergoing spleen autotransplantation. We studied 29 patients with severe trauma of the spleen and its pedicle. Of these, 20 underwent autotransplantation (group I) and 9 underwent total splenectomy without preservation of splenic tissue (group II). Twenty-two additional subjects with an intact spleen were used as controls (group III). Immediate and late postoperative complications were investigated. Laboratory counts were performed during the late postoperative period (red blood cells, hemoglobin, white blood cells, platelets, and Howell–Jolly bodies). To investigate the immunological profiles of patients we performed B- and T-lymphocyte counts and determined IgA, IgG, and IgM levels. All patients underwent splenic scintigraphy with technetium 99m sulfur colloid. Groups I and III did not present abnormal blood bodies, and their hematological and immunological patterns were normal. Group II showed increased numbers of Howell–Jolly bodies and low IgM levels. Splenic scintigraphy indicated the viability and filtering function of the splenic remnant in group I. Autotransplantation is a good option to maintain splenic function when total splenectomy is necessary.

Treatment of portal hypertension by subtotal splenectomy and central splenorenal shunt.

A method is proposed to reduce portal hypertension utilizing subtotal splenectomy and a central splenorenal shunt. The advantages of this method are: diversion of the splenic component of the portal circulation, creation of a shunt for the portal blood into the systemic circulation, preservation of the splenic function and correction of the manifestations of the hypersplenism. Two cases are presented who remain well four years after surgery.