José Ivan de Andrade

Comparison between Henley jejunal interposition and Roux-en-Y anastomosis as concerns enterogastric biliary reflux levels

The amount of enterogastric biliary reflux was assessed in patients who previously underwent Henley operation (n = 8) or Roux-en-Y biliary diversion (n = 7) using the radiopharmaceutical 99mTechnetium-DISIDA. Two other groups were investigated: a control group consisting of patients with unoperated duodenal ulcer (n = 10) and a group of patients who underwent Billroth II gastrectomy (n = 7). The length of the interposed segment of jejunum ranged from 20 to 30 cm (median of 22.5 cm) in the Henley patients, and from 30 to 60 cm (median of 40 cm) in the Roux-en-Y group. In Henley patients, the percentage of administered 99mTechnetium-DISIDA that was recovered from the stomach (median of 0.92%) was lower (p < 0.01) than that obtained for Billroth II patients (median of 32.28%) and did not differ (p > 0.10) from that of the Roux-en-Y (median of 0.36%) and duodenal ulcer groups (median of 2.53%). These results indicate that Henley operation is as effective as Roux-en-Y diversion in promoting the reduction of the amount of enterogastric biliary reflux that follows Billroth II distal gastrectomy.

Late evaluation of the relationship between morphological and functional renal changes and hypertension after non-operative treatment of high-grade renal injuries

ObjectiveTo evaluate the anatomical and functional renal alterations and the association with post-traumatic arterial hypertension.MethodsThe studied population included patients who sustained high grades renal injury (grades III to V) successfully non-operative management after staging by computed tomography over a 16-year period. Beyond the review of medical records, these patients were invited to the following protocol: clinical and laboratory evaluation, abdominal computed tomography, magnetic resonance angiography, DMSA renal scintigraphy, and ambulatory blood pressure monitoring. The hypertensive patients also were submitted to dynamic renal scintigraphy (99mTc EC), using captopril stimulation to verify renal vascular etiology.ResultsOf the 31 patients, there were thirteen grade III, sixteen grade IV (nine lacerations, and seven vascular lesions), and two grade V injuries. All the patients were asymptomatic and an average follow up post-injury of 6.4 years. None had abnormal BUN or seric creatinine. The percentage of renal volume reduction correlates with the severity as defined by OIS. There was no evidence of renal artery stenosis in Magnetic Resonance angiography (MRA). DMSA scanning demonstrated a decline in percentage of total renal function corresponding to injury severity (42.2 ± 5.5% for grade III, 35.3 ± 12.8% for grade IV, 13.5 ± 19.1 for grade V). Six patients (19.4%) had severe compromised function (< 30%). There was statistically significant difference in the decrease in renal function between parenchymal and vascular causes for grade IV injuries (p < 0.001). The 24-hour ambulatory blood pressure monitoring detected nine patients (29%) with post-traumatic hypertension. All the patients were male, mean 35.6 years, 77.8 % had a familial history of arterial hypertension, 66.7% had grade III renal injury, and average post-injury time was 7.8 years. Seven patients had negative captopril renography.ConclusionsLate results of renal function after conservative treatment of high grades renal injuries are favorable, except for patients with grades IV with vascular injuries and grade V renal injuries. Moreover, arterial hypertension does not correlate with the grade of renal injury or reduction of renal function.

The effects of Roux-en-Y limb length on gastric emptying and enterogastric reflux in rats

PURPOSE To assess the effects of Roux-en-Y jejunal limb length on gastric emptying and enterogastric reflux. METHODS Seventy male Wistar rats were submitted to antrectomy with Roux-en-Y reconstruction and then were divided into two groups of 35 animals. Group A, short limb (7.5 cm) and Group B, standard limb (15 cm). Group A and B were subdivided into five subgroups each in order to study enterogastric reflux at 30 and 60 minutes and to evaluate gastric emptying at 5, 10 and 15 minutes. In order to measure gastric emptying and enterogastric reflux, radiotracers 99m Tc-Phytate and 99m Tc-DISIDA were respectively used. RESULTS For gastric emptying, the radiotracer concentration was lower in Group A than in Group B after five minutes. The enterogastric reflux was present, but there were no significant differences between enterogastric reflux indexes concerning both A and B Groups. CONCLUSION A standard Roux limb, besides being unable to protect the stomach from the enterogastric reflux, may become a functional barrier for gastric emptying.

Neoplasia papilar cístico-sólida de pâncreas

The papillary cystic and solid tumor of the pancreas is rare. It occurs predominantly in young women and most present a benign behavior. The most common clinical sign is a large palpable abdominal mass. The pathogenesis of this tumor has attracted a number of investigations but remains unclear. We present a 18 year old white woman with abdominal mass detected after cesarian. Clinical examination showed minimal tenderness. There was no history of weight loss or jaundice. Haematological parameters were normal, except anaemia. The computed tomography was performed and surprisingly showed a 10 cm mass in the region of the tail of the pancreas. An extended distal pancreatectomy was performed with splenic preservation. The patient had an uneventful recovery and two months later remains asymptomatic.

Estudo comparativo entre o tratamento não-operatório e a cirurgia conservadora no trauma esplênico

Nas ultimas decadas, diversas alternativas tem sido propostas para o tratamento do trauma esplenico. O presente estudo procurou comparar o tratamento nao-operatorio e a cirurgia conservadora na lesao esplenica. Foram analisados, retrospectivamente, os prontuarios de 136 portadores de trauma esplenico atendidos na Unidade de Emergencia do Hospital das Clinicas da FMRPUSP (1986-1995). Foram utilizados o lnjury Severity Score (1SS) e o Organ lnjury Scaling (OIS) para a definicao da gravidade dos casos. Os pacientes foram divididos em dois grupos: grupo A (n=32): conservador nao operatorio e grupo B (n=104): cirurgia conservadora. As medias de idade, em anos, foram semelhantes (A: 20,31 + 12,43 e B: 25,02 + 14,98; p>0,05). Houve predominância do sexo masculino em ambos os grupos. Os dois grupos diferiram quanto a etiologia (p 0,05). Ocorreram complicacoes em 9,37% e 24,03% dos grupos A e B, respectivamente, mas a diferenca nao foi significativa (p>0,05). A media de permanencia hospitalar foi de 6,68 ± 5,65 e 9,24 ± 9,09 dias, grupos A e B, sem diferenca significativa (p>0,05). Concluimos, portanto: o tratamento nao-operatorio e a cirurgia conservadora do trauma esplenico sao condutas equivalentes, sendo opcoes terapeuticas validas nas lesoes esplenicas de menor gravidade.

Peritonite por bário

We report a case of a 49 years-old man who underwent a barium meal examination for an epigastric pain. A perforated gastric ulcer with barium extravasation into peritoneal cavity was seen on X-rays. During an emergency laparotomy, a perforated pyloric ulcer was noted, along with barium contamination in the peritoneal cavity. The ulcer was closed with an omental patch and an extensive peritoneal lavage with saline was performed. During the postoperative period, the patient developed signs of peritonitis and underwent a new laparotomy was at the 9th day showing a subfrenic abscess with a large barium contamination. The patient presented septic shock and multiple organ failure. dying on the 21th day.

Mudanças na vascularização arterial da curvatura menor do estômago após gastrectomia segmentar associada à vagotomia gástrica proximal em cães

In order to evaluate the possible effects determined by combined body segmental gastrectomy and proximal gastric vagotomy on the arterial vascularization of the lesser curvature of the stomach, twenty-four dogs. weighing 10 to 20 kg, were divided into two groups of 12 animals each: Group 1, animals were submitted to laparotomy and gastric manipulation for 30 minutes; Group II, animals were submitted to segmental gastrectomy with proximal gastric vagotomy. In each group, six animals were sacrificed on the third postoperative day and six on the eighth postoperative day. Neither death nor other postoperative complications occurred. On the sacrifice day barium-gelatin contrast was injected into the arterial vascularization of the stomach, which was then removed from the animal, opened along the greater curvature, fixed in formalin and submitted to radiographs. The intensity of the vascularization of the lesser curvature of the stomach was determined by microdensitometric and molphometric study. By means of microdensitometry. values of the optical densities were determined of the radiograph image of the lesser curvature of the stomach. Considering the microspectrophotometry principies. the values of the optical densities converted in aluminum equivalent were directly proportional to the intensity of vascularization of the gastric lesser curvature. The analysis of the obtained microdensitometry data revealed mean values of optical densities significantly more intense in group 11, when compared to group 1 (p 0.05). Therefore. it was found an increased intensity of the arterial vascularization of the lesser. The increased vascularization was consequence of arteriole dilatation of the submucosal layer.

Síndrome da alça aferente com necrose simulando pseudocisto de pâncreas

Afferent loop obstruction after gastrectomy and Billroth II reconstruction is an uncommon problem. Complete acute obstruction requires emergent laparotomy. We describe a patient who developed acute abdominal pain, hyperamylasemia, and palpable abdominal mass, five years after Billroth II gastrectomy. At laparotomy the patient was found to have a complete stricture of the afferent limb with evidence of strangulation and necrosis. There was no evidence of pancreatitis or pancreatic pseudocyst. The patient underwent pancreaticoduodenectomy plus degastrectomy and died 18 hours after the procedure in the ICU. The mass was initially inte1preted as pancreatic pseudocyst. Ultrasonography may provide enough evidence to differentiate a pancreatic pseudocyst. from an obstructed afferent loop, by the presence of a peripancreatic cystic mass or debris within the mass or the absence of the keyboard sign, suggesting effacement of the valvulae conniventes of the small bowel. Howewer, CT scan of the abdomen has been suggested to be highly characteristic, if not pathognomonic, for an obstructed afferent loop and should be considered first in patients with pancreatitis after Billroth II gastrectomy. A history of previous gastrectomy, recurrent or severe abdominal pain, hyperamylasemia with characteristic tomography, and endoscopic findings will establish the diagnosis and necessitate surgical evaluation and intervention.