Benedito Herani Filho

Endoscopic treatment of bleeding gastric varices using large amount of N-butyl-2-cyanoacrylate under fluoroscopic guidance.

Purpose We propose the use of fluoroscopic guidance for endoscopic injection of n-butyl-2-cyanoacrylate to treat gastric variceal hemorrhage to achieve placement of the safest quantity of tissue adhesive. Methods Ten patients with gastric varices were treated with n-butyl-2-cyanoacrylate endoscopic injection under fluoroscopic guidance for the purpose of hemostasis or prevention of recurrent bleeding. The glue was infused into the varices in the quantities needed to achieve complete obliteration of the gastric varices. Results The median quantity of tissue adhesive required in this series was 6.6 mL. The procedure was initially considered successful in all patients. There were no complications relating to the procedure. The mean duration of follow-up was 20 months. Conclusions Injection of suitable quantities of cyanoacrylate under fluoroscopic guidance seems to be safe and effective for controlling hemorrhagic gastric varices.

Castleman’s Disease Mimetizing Pancreatic Tumor

CONTEXT Angiofollicular lymph node hyperplasia or Castlemans disease is a rare clinical condition. Knowledge about etiology and physiopathology; and treatment management as well are yet to be defined. Unicentric presentation of this disease affecting single lymph nodes in the mediastinum seems to be the most common presentation. Castlemans disease localized in the pancreas topographic area that mimics a pancreatic neoplasm is an even more uncommon event, with available published data of less than 15 cases until now. CASE REPORT We present a 64-year-old male patient with a six-month past history of asthenia, adynamia, and lack of general clinical conditions. Imaging studies showed a nodular hypoechoic mass in the pancreatic head. Enucleation of the lesion was performed. Histopathological study revealed unicentric form of Castlemans Disease. CONCLUSIONS Castlemans disease mimetizing pancreatic tumor is uncommon and it also curses with a difficult preoperative diagnosis. Surgery seems to be the best therapeutic alternative for this disease.

H. PYLORI INFECTION, ENDOSCOPIC, HISTOLOGICAL ASPECTS AND CELL PROLIFERATION IN THE GASTRIC MUCOSA OF PATIENTS SUBMITTED TO ROUX-EN-Y GASTRIC BYPASS WITH CONTENTION RING: a cross sectional endoscopic and immunohistochemical study

BACKGROUND Morbid obesity treatment through vertical gastroplasty Roux-en-Y gastric bypass initially used a contention ring. However, this technique may create conditions to the development of potentially malign alterations in the gastric mucosa. Although effective and previously performed in large scale, this technique needs to be better evaluated in long-term studies regarding alterations caused in the gastric mucosa. OBJECTIVE To analyze the preoperative and postoperative endoscopic, histological and cell proliferation findings in the gastric antrum and body mucosa of patients submitted to the Roux-en-Y gastric bypass with a contention ring. METHODS We retrospectively evaluated all patients submitted to Roux-en-Y gastric bypass with a contention ring with more than 60 months of postoperative follow-up. We compared the preoperative (gastric antrum and body) and postoperative (gastric pouch) gastric mucosa endoscopic findings, cell proliferation index and H. pylori prevalence. We evaluated cell proliferation through Ki-67 antibody immunohistochemical expression. RESULTS In the study period, 33 patients were operated with the Roux-en-Y gastric bypass using a contention ring. We found a chronic gastritis rate of 69.7% in the preoperative period (gastric antrum and body) and 84.8% in the postoperative (gastric pouch). H. pylori was present in 18.2% of patients in the preoperative period (gastric antrum and body) and in 57.5% in the postoperative (gastric pouch). Preoperative cell proliferation index was 18.1% in the gastric antrum and 16.2% in the gastric body, and 23.8% in the postoperative gastric pouch. The postoperative cell proliferation index in the gastric pouch was significantly higher (P=0.001) than in the preoperative gastric antrum and body. Higher cell proliferation index and chronic gastritis intensity were significantly associated to H. pylori presence (P=0.001 and P=0.02, respectively). CONCLUSION After Roux-en-Y gastric bypass with contention ring, there was a higher chronic gastritis incidence and higher cell proliferation index in the gastric pouch than in the preoperative gastric antrum and body. Mucosa inflammation intensity and cell proliferation index in the postoperative gastric pouch were associated to H. pylori presence and were higher than those found in the preoperative gastric antrum and body mucosa.

Contribution Towards the Anatomy of the Esophageal Hiatus and its Relationship with the Presence of Bundles of Collagen Fibers in its Margins

El objetivo fue detectar la presencia de haces de fibras de colageno en los margenes del hiato esofagico y establecer si existe relacion de estos con la anatomia del hiato. Fueron utilizados 10 cadaveres de individuos adultos de sexo masculino, sin alteraciones anatomicas evidentes causadas por trauma, cirugia o enfermedad, sobre el hiato esofagico. Fue retirada y disecada una seccion anatomica que contendia el diafragma con el hiato esofagico y los tejidos adyacentes y luego fijada en formol 10%. Las medidas del perimetro del hiato esofagico se realizaron con ayuda de un caliper digital en los lados abdominal y toracico. Para el estudio estructural cada margen fue dividido en seis secciones y tenidos con Tricomico de Masson y Picrosirius-hematoxilina. En 8/10 cadaveres estudiados fueron encontrados haces de fibras colagenas, distribuidos en 13 margenes del hiato esofagico, 7 izquierdos y 6 derechos. Las fibras musculares que originaban el pilar derecho participaron en la formacion de ambos margenes del hiato esofagico en 60% de los cadaveres, mientras que en el 40%, las fibras del pilar izquierdo habian formado el lado intermedio del margen derecho. El margen derecho fue estadisticamente mas grueso que el izquierdo. No se encontro correlacion entre las medidas de los vertices de los angulos superior/inferior y la medida transversal del hiato esofagico. Las medidas entre los vertices de los angulos superior/inferior, respectivamente, con el tendon central y el ligamento arqueado mediano, presentaron valores toracicos que fueron casi el doble em relacion a los abdominales, y fueron estadisticamente significativos. Estas distancias eran mas pequenas en los cadaveres que tenian haces de fibras de colageno en las margenes del hiato esofagico. Los paquetes de fibras de colageno fueron encontrados en 65% de los 20 margenes del hiato del esofago. Los margenes del hiato esofagico fueron formados principalmente por fibras musculares originadas del pilar derecho del diafragma. Los datos anatomicos y morfometricos presentaron valores estadisticamente significativos en relacion con: espesor del lado derecho en relacion al izquierdo; distancia entre vertice del angulo superior y el tendon central y distancia entre el vertice del angulo inferior y el ligamento arqueado mediano.

Hypertonic glucose solution 10% - 25% on the mesenterium and peritoneum of the rat: macroscopic and microscopic study

PURPOSE The objective of the experimental study is to detect the macroscopic and microscopic alterations of the mesenterium and parietal peritoneum when hypertonic glucose aqueous solution 10%-25% is administrated into the peritoneal cavity of the rat. METHODS 90 Wistar females young rats adults were used weighing between 180-250 g, numbered 1 to 90, establishing unique group and divided in three groups (A, B, C) of 30 animals chosen aleatory manner. 0.9% saline solution was used called control group, or group A, 10% glucose solution named group B, and in the others 30 was used 25% glucose solution named group C, differing in the observation period, (06 h, 24 h and 48 h), but with the same procedure. A midline abdominal wall laparotomy was made and in the animals of the control group was injected 2 ml of a 0.9% saline solution into the peritoneal cavity. After, we made a suture in mass without to include the peritoneum. For the others groups (B, C) the rats received 10% glucose solution and 25% glucose solution injected into the peritoneal cavity respectively. All groups were kept under observation and the results were submitted to statistical analysis by a longitudinal and transversal comparative study. RESULTS A new surgery was done in 6 h, 24 h and 48 h, and we observed in macroscopic evaluation, the presence of fluid, serous uniform and rosy all over the cavity. Vascular congestion was present. We dried out 90 fragments of mesenterium and 90 fragments of parietal peritoneum bilateral. In the microscopic study, necrosis was not present. For the mesenterium histological study we observed 16 cases (17.8%) unspecific chronic inflammation, 30 cases (33.4%) hyperplasc linfonod, 10 cases (11.1%) high vascular congestion, 6 cases (6.6%) reaction fibrosis and 28 cases (31.1%) no alteration. For the parietal peritoneum histological study we observed 6 cases (3.3%) reaction fibrosis and 174 cases (96.7%) no alteration. Giant cell was not present. In the statistical analysis statistic there is no significance between the groups (p>0.05). CONCLUSION Hypertonic glucose solution and NaCl 0.9% on the mesenterium and parietal peritoneum do not produce tissue necrosis in a rat and the inflammation process has the same intensity.

Emergencia y Trayecto de las Arterias Epigástricas Superiores: Aplicación en los Abcesos Quirúrgicos Abdominales

El conocimiento de la vascularizacion de la pared anterior del abdomen es un importante instrumento para la realizacion de incisiones y punciones abdominales, contribuyendo a evitar algunas complicaciones reurrentes de este procedimiento. Con el proposito de estudiar la emergencia y el trayecto de las arterias epigastricas superiores, fueron disecados 32 cadaveres adultos, del sexo masculino, no fijados, blancos y no blancos, con edades entre 18 y 65 anos. Se observo el trayecto de las arterias epigastricas superiores, su emergencia y su forma de distribucion. Las arterias epigastricas superiores emergieron por atras del 7 cartilago costal en todos los casos. En el 75% de los casos las arterias epigastricas se presentaron como un tronco unico y en 15 casos (23,44%) bifurcadas, siendo 11 a la derecha y 4 a la izquierda y en 1 caso (1,56%) a la izquierda. En este ultimo, caso dio origen a tres ramos principales. Cuando era un tronco unico, su trayecto fue descendente de medial para lateral en relacion al margen lateral del musculo recto del abdomen. Cuando era bifurcada, sus ramos se separaron uno del otro luego de su emergencia, volviendo a convergir proximo a la cicatriz umbilical