Júlio Cezar Uili Coelho

A multivariate model to determine prognostic factors in gastrointestinal fistulas

BACKGROUND Some studies have identified and selected factors that were associated with prognosis in patients with gastrointestinal fistulas, but a multivariate analysis to determine their relative importance and independent predictive value has not been done. The aim of this study was to determine independent prognostic factors for fistula closure and death in patients with gastrointestinal fistulas using a multivariate model. STUDY DESIGN Several variables were assessed related to spontaneous closure, surgical closure, and mortality in 188 patients with digestive fistulas (duodenal 22.3%, jejunoileal 28.7%, colonic 23.9%, biliopancreatic 25%). Selection of the variables was done through a forward stepwise logistic regression procedure; the final models were used to estimate the probability of closure, either spontaneous or surgical, and the probability of death. RESULTS Variables significant for spontaneous closure were: cause of the fistula (p = 0.027), fistula output (p = 0.037), institutional origin of the patient (p = 0.026), and occurrence of complications (p<0.001). Organ of origin of the fistula was only marginally significant (p = 0.068). Successful surgical closure was significantly associated with the presence of complications (p = 0.001) and was marginally associated with age (p = 0.069). Variables significant for death were fistula output (p = 0.009) and the presence of complications (p<0.001). CONCLUSIONS We conclude that the likelihood of spontaneous fistula closure is higher for fistulas with surgical causes, low output, and with no complications. Mortality is higher in patients with complications and with high-output fistulas.

Endotoxemia after relief of biliary obstruction by internal and external drainage in rats

Systemic and portal endotoxemia were studied in rats with biliary obstruction and after relief of the obstruction by internal and external drainage. Endotoxemia was increased after bile duct ligation (p less than 0.001) compared with control values. The incidence of systemic and portal endotoxemia was significantly reduced after internal drainage (p less than 0.001). A significantly higher incidence of portal (86 percent) and systemic (57 percent) endotoxemia, however, was found after external drainage. The persistence of endotoxemia after external drainage, when serum bilirubin levels returned to normal units, indicates that bile flow is important in controlling endotoxemia during preoperative biliary drainage. These results suggest that the systemic endotoxemia observed after relief of obstruction by external drainage may contribute to the increased mortality, as found in previous rat studies. This observation may contribute to an understanding of why patients with preoperative external drainage of biliary obstruction have a higher incidence of septic complications.

Effect of Plasma Proteins and Temperature on Echogenicity of Blood

An explanation is proposed for the echogenicity to ultrasound scanning at 5 mHz and above of unclotted blood under conditions of stasis. In vitro experiments using blood from normal subjects and from patients with myeloma revealed that: 1) lysis of red cells prevented echogenicity, 2) echogenicity increased with increasing hematocrit, fibrinogen and other macromolecules, and temperature, and 3) blood from myeloma patients showed increased echogenicity and rouleau formation, a form of aggregation seen on peripheral smears. From these experiments it was concluded that red cell aggregation is a major cause of echogenicity of unclotted blood, requiring both intact red cells and conditions which are known to enhance red cell aggregation, such as the presence of macromolecules and increased temperature.

Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease

BACKGROUND Although several authors have documented the safety and efficacy of laparoscopic fundoplication, it is important to determine the rate of conversions and complications of this procedure. STUDY DESIGN We retrospectively reviewed the protocol sheets of 503 consecutive patients with gastroesophageal reflux disease who underwent laparoscopic fundoplication over a period of 5 years. A Nissen-Rosetti procedure was performed in 492 patients (97.8%) and a Toupet procedure in 11 (2.2%). Sixty-four patients were also subjected to a concurrent cholecystectomy, and one patient had a concurrent cervical pharyngoesophageal diverticulectomy with cricopharyngeal myotomy. Thirty-one patients had previous upper abdominal operations. RESULTS The period of hospitalization varied from 12 hours to 16 days, with an average of 1.2 days. The operation was converted to an open procedure in 10 patients (2%). The main cause of conversion was the presence of adhesions. The most frequent intraoperative complication was pneumothorax. All pneumothoraces occurred in the first 100 patients. Five patients had significant operative bleeding; two of them required laparotomy for bleeding control. Gastric ulcer was diagnosed in six patients. One alcoholic patient died of acute pancreatitis. Other major complications were two intraabdominal abscesses, one esophageal perforation, one sepsis from gastric perforation, one hemorrhagic shock, and one gastric obstruction from fundoplication herniation. CONCLUSIONS Conversions and complications of laparoscopic fundoplication are low and decrease significantly with the surgeon experience, but severe and lethal complications may occur.

Oral glutamine and the healing of colonic anastomoses in rats.

BACKGROUND Recent evidence has suggested that glutamine is one of the primary energy sources of the colon. The aim of this study was to evaluate the effects of oral glutamine supplementation on the healing of colonic anastomoses in rats. METHODS Forty-eight adult male Wistar rats, weighing 174.41 +/- 37.39 g, were housed in individual cages. All rats had free access to water and standard rat chow. The rats were randomized to receive daily, for 7 days before the operation and during the postoperative period, 10% L-glutamine (GLN group) or 10% glycine (GLY group) in isonitrogenous and isovolumetric solutions (1.5 g/kg per day), through an orogastric tube. On the eighth day, rats were anesthetized and subjected to 2 colonic transections, one 6 cm distal from the ileocecal valve and another 5 cm distal from the first transection. Bowel continuity was restored by 2 end-to-end, single layer, everted, anastomoses with 8 interrupted sutures (6-0 nylon). After the operation, the rats were kept in individual cages and had free access to water and rat chow. One-half of the rats in each group were killed either on postoperative day 3 or 8, and the 2 colonic anastomoses of each animal were resected and stored in 0.9% saline and 10% formalin for tensile strength and histologic (hematoxylineosin and collagen densitometry) studies, respectively. Students t-test and Kruskal Wallis tests were used for statistical analysis. RESULTS Total rupture strength was significantly higher in the GLN group (GLN: 0.068 +/- 0.045 kgf versus GLY: 0.042 +/- 0.027 kgf, p = .04). The mean monocytes infiltrate was significantly smaller in the GLN group (p = .04). The collagen densitometry analysis demonstrated greater percent area of type I (mature) in the GLN group compared with GLY (58.65 +/- 11.70% versus 41.79 +/- 10.54%, p = .0000), respectively. Subgroup analyses according to the day of rat death were still significant: GLN 3: 54.22 +/- 10.02% versus GLY 3: 41.92 +/- 13.31% (p = .04) and GLN 8: 62.63 +/- 12.13% versus GLY 8: 41.67 +/- 7.69% (p = .0004). Type III collagen (immature) percent area was significantly smaller in the GLN groups colonic anastomoses (GLN: p = .0000; GLN 3: p = .04 and GLN 8: p = .0003, respectively). CONCLUSIONS Perioperative oral glutamine supplementation increases total rupture strength and improves the percent area of mature collagen at the anastomoses sites on postoperative days 3 and 8.

Late laparoscopic reoperation of failed antireflux procedures.

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.

FACTORS INFLUENCING OUTCOME IN PATIENTS WITH GASTROINTESTINAL FISTULA

The analysis of the prognostic factors in patients with gastrointestinal fistula requires an assessment of the quantitative and qualitative characteristics of the study population. General patient characteristics such as age, presence and degree of malnutrition, levels of plasma proteins, diagnosis of cancer or inflammatory bowel disease, or systemic sepsis must be considered, as well as local fistula characteristics. Besides the local anatomic characteristics of the fistulous tract, other factors such as fistula output, organ of origin, cause, and duration of the fistula must be considered in the assessment of a fistula patient. It is recognized, however, that it is very difficult to conclude that the presence of a single prognostic factor increases the risk in patients as complex and heterogeneous as those with digestive fistulas. It remains to be shown whether the combination of several predictive factors may enhance the chances of accurately predicting fistula closure and mortality in digestive fistulas.

Nutritional aspects of liver transplantation.

Most adult and pediatric liver transplantation candidates present several metabolic disturbances that lead to malnutrition. Because malnutrition may adversely affect morbidity and mortality of orthotopic liver transplantation, it is very important to carefully assess the nutritional status of the waiting list patients. Pretransplant nutritional therapy - enteral or parenteral - may positively influence liver metabolism, muscle function, and immune status. Nutrition therapy should continue in the short- and also in the long-term post-transplant periods. For malnourished patients, early post-transplant enteral or parenteral nutrition have been useful in improving nutritional status. Finally, the metabolic and nutritional care of the liver transplant donor must be considered to reduce allograft dysfunction indices.

Ultrasonic imaging during biliary and pancreatic surgery

Real-time ultrasound scanning was used during operations on the biliary tract and pancreas. The principal application in biliary surgery was to evaluate the common bile duct for presence of calculi. Our initial experience indicates that operative ultrasonography compares favorably with operative cholangiography. In pancreatic operations, ultrasound has been helpful in the management of pseudocysts and chronic pancreatitis. For pseudocysts, ultrasonography has indicated cyst wall thickness and the presence of adjacent anatomic structures. Ultrasound has distinguished the fluid loculations of the pseudocyst from swelling due to inflammatory edema. In surgery for chronic pancreatitis, ultrasonography has revealed the size and location of pancreatic ducts. This information has been useful in helping select sites for internal drainage of pseudocysts and in chronic pancreatitis with ductal dilatation. Operative ultrasonography is a relatively simple procedure which has the potential for providing the surgeon with early information and decreasing the need for dissection and radiographic imaging.

Motility of Oddi's sphincter: Recent developments and clinical applications

BACKGROUND In recent years, applications of electromyographic, cineradiographic, scintilographic, and endoscopic manometric techniques have improved our knowledge of normal and abnormal motility of Oddis sphincter. This sphincter coordinates the time and rate of secretion of about 3 liters of bile and pancreatic juice into the duodenum daily. METHODS Oddis sphincter may be evaluated by endoscopic manometry, ultrasound, dynamic hepatobiliary scintigraphy, and laboratory tests. Endoscopic manometry is the best method for evaluating the function Oddis sphincter. RESULTS The basal pressure of Oddis sphincter is usually 5 to 15 mm Hg greater than the bile and pancreatic duct pressures. Phasic contractions of 50 to 150 mm Hg in amplitude and 3 to 8 contractions per minute in frequency are superimposed on the basal pressure. A small percentage of patients with gastrointestinal symptoms after cholecystectomy has sphincter of Oddi dysfunction, which may have structural abnormality (papillary stenosis) or functional abnormality (Oddis sphincter dyskinesia). CONCLUSIONS Elevated basal pressure ( > 40 mm Hg) is the most important manometric finding of Oddis sphincter dysfunction. Endoscopic sphincterotomy is the treatment of choice for patients with Oddis sphincter dysfunction and elevated basal sphincter pressure.