Cleber Soares Junior

Uso de 2-octil cianoacrilato em anastomose colônica: estudo experimental em ratos wistar

OBJECTIVE: To compare the effect of 2-octyl cyanoacrylate tissue adhesive with polypropylene suture on the healing of colonic anastomosis in Wistar rats. METHODS: Thirty two animals, divided in four groups of eigth, were established concerning suture with Polypropylene or Cyanoacrylate application, and the day chose for euthanasia: third or seventh day following operation. In the control group, the anastomosis was done in a single layer with 5.0 polypropylene suture. In the adhesive group, the anastomosis was performed by using 2-octyl cyanoacrylate. Operative time, integrity and gross anastomotic healing, bursting pressure, intestinal obstruction, adhesions formation, histological healing and inflammatory process were recorded. RESULTS: Adhesion formation was more extensive in the cyanoacrylate group on the seventh postoperative day comparing with suture group (p=0.007). Mechanical strength of the anastomosis assessed on the seventh postoperative day was lower in 2-octyl cyanoacrylate group (p=0.002). Partial intestinal obstruction rate were more frequent in anastomosis using 2-octyl cyanoacrylate compared to those with polypropylene suture on the seventh postoperative day (p=0.029). Operative time were longer in groups with adhesive (p=0.004). The wound healing process, and inflammatory process did not differ statistically between groups (p>0.05). CONCLUSION: The application of 2-octyl cyanoacrylate, under experimental conditions seems to be detrimental at the seventh day of the healing, causing intense adhesion formation, colonic obstruction; and impairment healing with less mechanical strength resistance.

Tratamento cirúrgico do divertículo de zenker

O diverticulo de Zenker (DZ) e uma doenca muito pouco frequente, cujo sintoma mais importante e a disfagia cervical. Os aspectos de sua etiopatogenia ainda sao motivos de varias pesquisas na literatura, atraves de estudos manometricos e cinerradiograficos. O tratamento mais empregado e o cirurgico, favorecendo quase a totalidade dos doentes, com indices de recidiva muito baixos. Porem, algumas publicacoes enfatizam as vantagens do tratamento endoscopico. Foram revisados 39 doentes, tratados no Servico nos ultimos 15 anos, sendo que 28 foram do sexo masculino (71,8%). A idade do grupo variou de 18 a 86 anos (media 54,5 anos). Os principais sintomas foram a disfagia cervical (89,8%), a regurgitacao alimentar (71,8%), a tosse repetitiva (30.7%) e o emagrecimento importante (25,6%). Dois pacientes apresentaram diverticulite aguda e perfuracao (5,1 %). O diagnostico foi estabelecido atraves de radiografias contrastadas em 37 pacientes (94,8%) e de endoscopia digestiva em 28 (71,7%). A eletromanometria foi realizada em 13 casos (33,3%). O tratamento consistiu de diverticulectomia seguida de miotomia do esfincter do musculo cricofaringeo em 24 pacientes (61,5%) e diverticulopexia seguida da mesma miotomia em 15 pacientes (38,5%). No seguimento a longo prazo de 35 pacientes (89,8%), variando de cinco meses a 12 anos (media 4,5 anos), ocorreu melhora importante com desaparecimento da disfagia em todos os casos. Tres pacientes (7,7%) persistiram sintomas disfagicos leves e inconstantes. Um paciente faleceu em decorrencia de complicacoes cardiacas e pulmonares. Os estudos histopatologicos dos diverticulos ressecados mostraram a presenca de tumor maligno neuroendocrino em um paciente (2,5%). Os doentes submetidos a diverticulopexia receberam alta hospitalar mais precocemente. Os autores discutem os aspectos atuais da fisiopatologia do DZ, analisam as opcoes de tratamento e os resultados da literatura, comparando com os obtidos neste estudo. Concluindo, os resultados mostram que tanto a diverticulectomia como a diverticulopexia podem ser utilizadas, ambas seguidas de miotomia do musculo cricofaringeo. A diverticulopexia mostrou ser uma opcao muito satisfatoria para os diverticulos de tamanhos pequenos e medios.

Acute calculous cholecystitis: Review of current best practices

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

Metastatic and Synchronous Melanoma in the Testicle and Paratesticular Region

Background: Metastatic tumors of the testicles are rare (0.8%) and preferably located in the testicular parenchyma or, much more rarely, in the para-testicular region. The melanoma of the skin represents the third primary site of metastases and the patients may present with increased scrotum volume, heterogeneous testicle mass beside local pain and tenderness. Objective: To show the rare case of metastatic and synchronous melanoma in the testicle and para-testicular region. Description of the case: Case reports of a 74-year-old male patient who was undergone an extended acral melanoma resection in the left calcaneus. The micro stage showed Clark level IV and Breslow depth of 3 mm. The treatment was complemented with homolateral inguinal-iliac lymphadenectomy. Three years later a crossed metastasis was diagnosed in the opposite inguinal region that required another lymphadenectomy. The patient developed a perineal lymphedema that was managed clinically. He was then carried to oncologist who starts high-dose interferon per one year as adjuvant therapy. Two years later, the patient showed an increased size and irregularity of the right testicle along with pain and loss of elasticity. An ultrasound confirmed an increased testicle diameter and increased vascularization associated with parenchyma heterogeneity. The measurements of LDH, alpha-fetoprotein and βHCG were normal. A staging computed tomography scans showed bilateral pulmonary nodules and increased diameter of periaortic lymph nodes representative of metastatic disease. A radical right orchiectomy via the inguinal route was then expedited. The histopathology diagnosed synchronous metastatic melanoma in the testicle and paratesticular region. Conclusion: The presence of a testicular mass in patients with previous clinical history of melanoma represents a warning sign. It should be considered a metastatic disease at first time and an accurate diagnostic restage is mandatory.

Tolerância, coragem e compaixão: virtudes cardinais do cirurgião

Interactions among human beings are very complex. Using only an ethical code as reference to deal with moral conflicts is hardly ever enough. Responsibility ethics demand such a profound reflection as well as a discussion about human essence and its role in society. The responsibility of a surgeon is inherent in a profession based since its origin, not only on altruism and humanity, but also on compassion, courage and tolerance. The studies and the comprehension of these qualities as well as the transmission of these values to the students and to the surgery residents are essential for human education of these individuals. This essay offers to show that these essential virtues are strongly connected to the work the surgeon develops whereas his/her responsibility starts before the surgery - when one intends to act.

Complicações biliares do transplante hepático com o emprego ou não do tubo em T

O aperfeicoamento da tecnica operatoria do transplante hepatico reduziu o numero de complicacoes biliares, mas os indices de morbidade e mortalidade relacionadas a estas complicacoes ainda preocupam os cirurgioes. Assim, e importante avaliar novas opcoes terapeuticas relativamente aos procedimentos operatorios convencionais. De setembro de 1991 a setembro de 1998, foram analisadas as complicacoes biliares observadas em 78 pacientes submetidos ao transplante hepatico; anastomose coledococoledociana com emprego do tubo em T (CCT) foi praticada em 16 pacientes ou 20,5%, anastomose coledococoledociana sem a utilizacao do tubo em T (CC) em 50 ou 64,1% e anastomose coledocojejunal (CJ) em 12 ou 15,4%. Foram observadas 24 (31,2%) complicacoes biliares sendo 12 durante o 1o mes e as demais no pos-operatorio tardio. Ocorreram 12/78 (15,6%) fistulas (CCT = 5, CC = 6, CJ = 1), 9/78 (11,7%) estenose (CCT = 1, CC = 8) e 3/78 calculose (CCT = 1, CC = 2). A colangiopancreatografia retrograda endoscopica (CPRE) realizada em 19/78 pacientes ou 24,7% ofereceu resultados satisfatorios em 13 (61,9%). O tratamento endoscopico foi praticado em 11 casos de fistula biliar oferecendo bons resultados em quatro do grupo CCT e 5/6 do grupo CC; por outro lado, nos oito casos de estenose da anastomose (grupo CC) o tratamento endoscopico mostrou-se eficiente em 4/8 pacientes. Complicacoes biliares ocorreram em 7/16 casos ou 43,75% (grupo CCT) e 16/50 ou 32% do grupo CC, somente nove entre as 24 complicacoes biliares necessitaram de reoperacoes (CCT = 1, CC = 8). Alem destas, entre os 78 , ocorreu trombose da arteria hepatica (T.A.H.). Nesta casuistica ocorreram 8/78 (10,4%) obitos (5 T.A.H., 1 CCT e 2 CC). O tempo de seguimento medio pos-tratamento das complicacoes biliares foi de 14 meses variando de um a 6,8 anos. A incidencia global das complicacoes biliares observadas nesta serie consecutiva de 78 pacientes foi maior nos grupos CCT (7/16) CC (16/50) quando comparadas ao grupo CJ. Nao houve diferencas significativa quanto a ocorrencia de fistula e estenoses nos grupos CCT e CC, quando comparadas. A incidencia de complicacoes biliares precoces e tardias foi semelhante em ambos os grupos CCT e CC. Estes resultados sugerem que a incidencia de fistulas e estenoses biliares, nao e significativamente pelo emprego do tubo em T. O tratamento endoscopico indicado em casos selecionados permite diagnostico acurado apresentando-se como tratamento de primeira escolha frente a estas complicacoes.

Mucinous neoplasm of the appendix: management according to reviewed histologic spectral aspects

Of the diseases affecting the cecal appendix, mucinous neoplasms, although rare, are the most common epithelial tumor. They are often asymptomatic and diagnosed by anatomopathological exams of sections, collected during appendectomies due to acute appendicitis. These tumors have the potential to become malignant, and their early surgical handling are the most important prognostic factor. So, clinical, image, operatory and histologic spectral aspects should always take into account. The present study reports a case of mucinous neoplasm of the appendix that manifested with intestinal partial obstruction and suggests the need for a comprehensive and uniform classification, which could address the best disease first approach. The information was obtained through a patient records review, photographic documentation of the diagnostic tests and histologic study of operative specimen. In addition, the manuscript opens a discussion about the approach of choice of this complex neoplasia, since great variability persists in clinical and pathological records, due to variations in classifications and definitions. This variability in disease nomenclature may significantly impact the treatment and prognosis.

Splenectomy in non-traumatic diseases

Splenectomy represents the first choice for treatment of spontaneous splenic rupture, abscesses, cysts, tumours, and an alternative for control of hereditary, autoimmune, and myeloproliferative disorders. However, its relative indications have been reviewed for better understanding of both the primary affections and of splenectomy per se, particularly with regard to the immune system. The emergence of minimally invasive surgery, the possibility of splenic preservation, and availability of biological therapy has shown that the procedure has often been referred to as salvage therapy upon failure of other therapeutic propositions. On the other hand, patients have their general health status compromised by the underlying disease, by the use corticosteroids or biologic therapy, immunosuppressed, coagulation disorders, which contribute to the incidence of postoperative complications, such as infections, bleeding and venous thrombosis. Therefore, this scenario favours higher morbidity and mortality rates than those of other intra-abdominal surgical procedures. Thus, this review has the primary and comprehensive objective of purpose the best moment for splenectomy, when surgeons can interfere in the natural course of the disease increasing patients’ quality of life and survival. In short, it is desired that the surgeon has complete knowledge of the profound physiological changes imposed on the host. In addition, to distinguish when it is curative and mandatory from when it must be put on hold due to other non-operative treatments with similar outcomes and, lastly, when it is not recommended for not aggregating survival.