Geni Satomi Cunrath

Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141]

IntroductionPreventing perioperative tissue oxygen debt contributes to a better postoperative recovery. Whether the beneficial effects of fluids and inotropes during optimization of the oxygen delivery index (DO2I) in high-risk patients submitted to major surgeries are due to fluids, to inotropes, or to the combination of the two is not known. We aimed to investigate the effect of DO2I optimization with fluids or with fluids and dobutamine on the 60-day hospital mortality and incidence of complications.MethodsA randomized and controlled trial was performed in 50 high-risk patients (elderly with coexistent pathologies) undergoing major elective surgery. Therapy consisted of pulmonary artery catheter-guided hemodynamic optimization during the operation and 24 hours postoperatively using either fluids alone (n = 25) or fluids and dobutamine (n = 25), aiming to achieve supranormal values (DO2I > 600 ml/minute/m2).ResultsThe cardiovascular depression was an important component in the perioperative period in this group of patients. Cardiovascular complications in the postoperative period occurred significantly more frequently in the volume group (13/25, 52%) than in the dobutamine group (4/25, 16%) (relative risk, 3.25; 95% confidence interval, 1.22–8.60; P < 0.05). The 60-day mortality rates were 28% in the volume group and 8% in the dobutamine group (relative risk, 3.00; 95% confidence interval, 0.67–13.46; not significant).ConclusionIn patients with high risk of perioperative death, pulmonary artery catheter-guided hemodynamic optimization using dobutamine determines better outcomes, whereas fluids alone increase the incidence of postoperative complications.

Rectosigmoidectomy with ileal loop interposition: A new surgical method for the treatment of chagasic megacolon

PURPOSE Chagasic megacolon occurs frequently in central Brazil. There are several surgical techniques for the treatment of megacolon and no consensus on which one is the best. Our goal is to present a new surgical treatment for chagasic megacolon. METHODS One hundred forty-seven patients with chagasic megacolon were submitted to surgical treatment between January 1985 and December 1995. Fourteen patients were lost to follow-up because they could not be reached. Patients were evaluated preoperatively and submitted to rectosigmoidectomy with interposition of an isoperistaltic segment of ileum between the descending colon and the rectum. RESULTS There were three deaths in the postoperative period, two because of complications caused by septic peritonitis and one because of hypovolemic shock. Major complications occurred in 5.4 percent of the cases: four dehiscences at the ileocolic anastomosis and two at the ileorectal anastomosis. Minor complications corresponding to 3.1 percent of the total included two with abdominal wall infection, one with a temporary infection, and one with a cardiac arrhythmia. Four patients (3.1 percent) had recurrence of constipation. CONCLUSION Rectosigmoidectomy with interposition of an ileal segment is a new therapeutic option for chagasic megacolon that has several advantages in relation to the other techniques because of its ease of execution, lack of complications such as those seen in pull-through procedures, and a low recurrence rate.

Terminal ileum of patients who underwent colonoscopy: endoscopic, histologic and clinical aspects

CONTEXT For the diagnosis of the diseases which affect the terminal ileum, the colonoscopy allows macroscopic evaluation and the performing of biopsies. Studies with criteria for the endoscopic and histological characterization of this segment are scarce and there are still some doubts about the need of biopsies in patients with normal ileoscopy. OBJECTIVE Study the terminal ileum of patients who underwent colonoscopy considering: endoscopic and histological correlation; agreement between results of the initial histological evaluation and slides review, and the chance of subjects with normal ileoscopy with abdominal pain and/or chronic diarrhea to show histological alterations. METHODS In a prospective study, 111 patients who presented smooth mucosa without enanthema in the endoscopic exam of the terminal ileum were selected. Biopsies of the ileal mucosa of such patients were performed, being the slides routinely examined and reviewed afterwards. RESULTS The correlation between patients with normal ileoscopy and ileum with preserved histological architecture was of 99.1%. The agreement between initial histological evaluation and slides review calculated by the Kappa test was 0.21. In patients with abdominal pain and/or chronic diarrhea, the chance of showing histological alterations was 2.5 times higher than the others. CONCLUSIONS The correlation between endoscopic and histological findings was high. The agreement between the initial histologic evaluation and slides review was not satisfactory. The chance of subjects with normal ileoscopy with abdominal pain and/or chronic diarrhea, showing histological alterations was higher in relation to the asymptomatic ones or with other symptoms, although the clinical importance of this datum was not evaluated.

Rectosigmoidectomy With Ileal Loop Interposition

AbstractPURPOSE: Chagasic megacolon occurs frequently in central Brazil. There are several surgical techniques for the treatment of megacolon and no consensus on which one is the best. Our goal is to present a new surgical treatment for chagasic megacolon. METHODS: One hundred forty-seven patients with chagasic megacolon were submitted to surgical treatment between January 1985 and December 1995. Fourteen patients were lost to follow-up because they could not be reached. Patients were evaluated preoperatively and submitted to rectosigmoidectomy with interposition of an isoperistaltic segment of ileum between the descending colon and the rectum. RESULTS: There were three deaths in the postoperative period, two because of complications caused by septic peritonitis and one because of hypovolemic shock. Major complications occurred in 5.4 percent of the cases: four dehiscences at the ileocolic anastomosis and two at the ileorectal anastomosis. Minor complications corresponding to 3.1 percent of the total included two with abdominal wall infection, one with a temporary infection, and one with a cardiac arrhythmia. Four patients (3.1 percent) had recurrence of constipation. CONCLUSION: Rectosigmoidectomy with interposition of an ileal segment is a new therapeutic option for chagasic megacolon that has several advantages in relation to the other techniques because of its ease of execution, lack of complications such as those seen in pull-through procedures, and a low recurrence rate.

Prevalence of rectoanal inhibitory reflex in chagasic megacolon

BACKGROUND Rectoanal inhibitory reflex is not always evident in patients with chagasic megacolon. This may be due to insufficient volumes of air used during insufflation for the manometric examination. AIMS To identify the volume of air necessary to induce rectoanal inhibitory reflex in patients with chagasic megacolon and to observe its prevalence in these individuals. METHODS Rectoanal inhibitory reflex in 39 patient with chagasic megacolon was studied by means of anorectal manometry using the balloon method. The balloon was insufflated using sequential volumes up to 300 mL to induce reflex. RESULTS Rectoanal inhibitory reflex was identified in 43.6% of the patients using a mean volume of 196 mL of insufflated air (standard error = 13.5). CONCLUSION Rectoanal inhibitory reflex can be induced in patients with chagasic megacolon when greater volumes of air are used.

Appendicular endometriosis as a cause of chronic abdominal pain alone in the right iliac fossa: case report and literature review

Endometriosis is a disease characterized by the presence of ectopic endometrial glands and stroma. Although its etiology is undefined, it is suggested to be a result of coelomic metaplasia, retrograde menstruation, to provide a genetic component, or to be one that occurs due to blood or lymphatic spread. The involvement of the gastrointestinal tract is common. However, appendicular endometriosis is a rare condition. It is usually asymptomatic. Recurrent pain in the right iliac fossa is an unusual clinical manifestation. There are no non-invasive complementary tests to confirm the diagnosis. Laparoscopy is the main option for research, due to its diagnostic and therapeutic features. A histopathological examination is necessary for the diagnosis. Although surgical and drug therapies have special indications, the combination therapy showed lower symptom recurrence. This study reports a case of appendicular endometriosis that was diagnosed and treated in the service of Coloproctology of the Base Hospital at Faculdade de Medicina of Sao Jose do Rio Preto. There is also a literature review about this situation.

Intestinal obstruction caused by phytobezoar composed of jaboticaba seeds: case report and literature review

Bezoar is a cluster of swallowed and undigested material in the gastrointestinal tract which can cause intestinal obstruction. It has multiple subtypes and the phytobezoar (composed of vegetable fiber) is the most common. We report a patient admitted with intestinal obstruction caused by impaction of multiples seeds of jaboticaba in the rectum. The treatment included multiple enemas, laxatives and digital maneuvers and it was effective after four days. Only one similar report was found in the literature.