Manlio Basílio Speranzini

Hepatosplenic schistosomotic portal hypertension: effect of esophagogastric devascularization with splenectomy on the diameter and mean flow velocity in the portal system (ultra-sonographic Doppler study)

Racional - A esplenectomia com desconexao azigo-portal tem sido indicada para o tratamento da hemorragia digestiva pelas varizes esofagicas na hipertensao portal da esquistossomose mansonica hepatoesplenica. Todavia, esta tecnica terapeutica apresenta indices variaveis de complicacoes tromboticas precoces do sistema portal (13,3% a 53,2%). Supondo que as alteracoes circulatorias devidas ao tratamento cirurgico tenham papel preponderante neste acontecimento, procurou-se identificar elementos hemodinâmicos que, dentre os multiplos fatores causais, tenham facilitado a ocorrencia desta complicacao. Com este intuito estudou-se comparativamente, mediante ultra-sonografia com Doppler, o sistema portal de dois grupos de pacientes em condicoes clinicas semelhantes: nao-operados e com desconexao azigo-portal em fase pos-operatoria tardia (periodo superior a 6 meses). Casuistica/Metodo - Foram estudados 58 pacientes com esquistossomose mansonica hepatoesplenica e com antecedentes de hemorragia digestiva alta, divididos em dois grupos: A (29 sob controle ambulatorial: clinico e endoscopico); B (29 submetidos previamente a desconexao azigo-portal). Em todos foi feita a medida do diâmetro e da velocidade media de fluxo do sangue na veia porta e seus ramos direito e esquerdo, mediante ultra-sonografia com Doppler. Os resultados foram submetidos a analise univariada inter e intragrupo. Resultados - No grupo A (nao-operados): a veia porta apresentou diâmetro maior do que o dos ramos direito e esquerdo e nestes esta medida foi semelhante (10,6 ± 2,9, 8,0 ± 1,8, 9,1 ± 2,6 cm); a velocidade media de fluxo na veia porta e nos ramos portais foi semelhante (15,62 ± 6,17, 14,92 ± 5,33, 16,12 ± 4,18 cm/seg). No grupo B (operados): houve diminuicao de ambos os parâmetros na veia porta e seus ramos (8,8 ± 1,7, 5,2 ± 1,2, 7,5 ± 2,2 cm/12,53 ± 2,60, 8,86 ± 1,75, 9,60 ± 3,75 cm/seg). Conclusoes - Houve reducao significativa do diâmetro e da velocidade media de fluxo sanguineo no sistema portal, no pos-operatorio tardio, em pacientes com esquistossomose mansonica hepatoesplenica, submetidos a desconexao azigo-portal.

MODELO DE DISPOSITIVO PARA TREINAMENTO E AVALIAÇÃO DAS HABILIDADES EM TÉCNICA OPERATÓRIA

Com o objetivo de facilitar o aprendizado da tecnica operatoria, em especial na realizacao de nos e suturas cirurgicas, foi desenvolvido um modelo experimental nao biologico, contendo dispositivos simples que simulam diversas situacoes encontradas no procedimento cirurgico fundamental

Estudo da utilização no pré-operatório de medicamentos ou drogas fitoterápicas que alteram a coagulação sangüínea

BACKGROUND: To verify the frequency usage of nonprescription drugs and/or herbal medicines that coud interfere with blood coagulation. Also it is evaluated when this information has not been told to the surgeon. If this information had been known by the surgeon what attitude has been taken by the attending surgeon. METHOD: Four hundred and sixteen patients from the Hospital Universitario de Taubate (HUT) in Regional Hospital de Taubate (HRT) and in private plastic surgery clinic were studied on preoperative basis. A thorough search with quantitative and qualitative variables of nonprescription drugs (aspirin and E vitamin) and herbal medicines (Ginkgo biloba, Garlic and Ginger )was undertaken. Data were obtained though a questionnaire related to the use of these medications from one year and 10 days before surgery. It was computed if the surgeon has been informed of its use and what attitude had been taken about withdrawing or nor this medication. RESULTS: Most of the patients (58.89%) have not used any of these drugs, 39% have used them the last year and 13.83% have used them in the last 10 days. Aspirin was the medicine most used and Ginkgo biloba was the preferred among the herbal medicines. The consumption of these drugs has been informed in 73.69% of the patients that had used them. CONCLUSION: In the studied population it is high the percentage of the use of drugs that interferes in the blood coagulation. The most frequent medications are:Aspirin, E vitamin and Ginkgo biloba. Most of the researched patients did not inform the surgeon about its use.It should be emphasized the need of questioning the use of these drugs before surgery, with the objective of reducing possible hemorrhage complications per and postoperatively, becauseof its medical complications and possible legal implications.

Clinical regression of infected pancreatic necrosis

SummaryInfected pancreatic necrosis was diagnosed clinically and radiologically in a patient admitted for acute pancreatitis. As free gas in the pancreatic area was recognized, antibiotic therapy (ceftriaxone) was empirically introduced, whilesurgical drainage was being planned. After the second week, the patient rapidly started to improve, to the point that he could be discharged home without operation. Control CT-scans and general laboratory tests, at this phase and later on, confirmed a still enlarged gland but free of infection or ongoing inflammation. Cholelithiasis, which had been identified in an early ultrasound scan, was electively treated by cholecystectomy 2 mo after the onset of pancreatitis, in the absence of sepsis, and with uneventful recovery. This case illustrates the rare possibility of spontaneous regression of infected necrotic pancreatitis, without any type of operation or nonoperative drainage.

Avaliação manométrica anal pré e pós tratamento da fissura anal crônica com nifedipina tópica 0,2%

In the treatment of the anal fissure, calcium channel blockers are among the new drugs which have been used. The objective of this research was the manometric evaluation of patients with chronic anal fissure after topic treatment with 0.2% nifedipine and correlation with the healing and pain. This is a prospective study of patients from Coloproctology Clinic of the University of Taubate Hospital. The patients had been submitted to a manometric examination before and after 30 days of the use of topic 0.2% nifedipine gel three times a day in the anus and anal edge. For the statistics analysis Mann-Whitney test was applied to a significance of p= 0,05. Ten patients did not exihibit manometric alteration associated with nifedipina treatment, however 50% of them reported improvement of the symptoms and 40% depicted healing of the fissure. The results demonstrated that nifedipine was effective and safe for anal fissure treatment and considering the functional point of view it did not cause injuries as well. The manometric evaluation did not demonstrate alterations in the anal pressure; however, it was observed that 50% of the patients had improvement in pain and 40% in healing.

VEIA PARAUMBILICAL PÉRVIA: importância hemodinâmica na hipertensão portal por esquistossomose mansônica hepatoesplênica. (Estudo com ultra-sonografia Doppler)

Background x97 The hemodynamical effect of the collateral portosystemic circulation upon the portal system has not yet been fully understood. The US-Doppler made possible the non-invasive study of the portal system by evaluating the parameters: flow direction, diameter and flow velocity in its vessels. Aims - To study the paraumbilical vein as a collateral portosystemic pathway and identify patterns for appraising its hemodynamic importance to the portal system. Method - US-Doppler study of the portal system of 24 patients with Mansonis hepatosplenic schistosomic portal hypertension, previous esophagic variceal bleeding and patent paraumbilical vein with hepatofugal flow. The diameter and the mean flow velocity were measured in the paraumbilical vein and so were the mean flow velocity in the portal vein, right and left portal branches. The Pearson test (linear correlation) was applied to the portal veins mean flow velocity and the paraumbilical veins diameter and mean flow velocity. The patients were divided in four groups: D1 - paraumbilical vein with diameter <0.68 cm (n = 14), D2 - paraumbilical vein with diameter ³0.68 cm (n = 10), V1 - paraumbilical vein with mean flow velocity <18.41 cm/seg (n = 13) and V2 - paraumbilical vein with mean flow velocity ³ 18.41 cm/seg (n = 11). The mean flow velocity in the portal vein, right and left portal branches of the four groups were compared. Results - The paraumbilical vein diameter was 0.68 ± 0.33 cm (range: 0.15 - 1.30 cm) and the mean flow velocity was 18.41 ± 11.51 cm/seg (range: 5.73 - 38.20 cm/seg). The linear correlation between the portal veins mean flow velocity / paraumbilical vein diameter and the paraumbilical veins mean flow velocity showed r = 0.504 and r = 0.735, respectively. In the group D2 there was an increase in the mean flow velocity in the portal vein (17.80 ± 3.42 / 22.30 ± 7.67 cm/seg) and in the left portal branch (16.00 ± 4.73 / 22.40 ± 7.90 cm/seg). In the group V2 there was an increase in the mean flow velocity in the portal vein (16.31 ± 3.49 / 21.96 ± 5.89 cm/seg) and in the left portal branch (14.22 ± 4.41 / 21.94 ± 7.20 cm/seg). There was no change in the right portal branch (13.67 ± 5.74 / 15.43 ± 3.43 cm/seg). Conclusions - In portal hypertension due to hepatosplenic schistosomiasis, the patent paraumbilical vein, with hepatofugal flow, diameter ³ 0.68 cm and mean flow velocity ³ 18.41 cm/seg causes an increase of the mean flow velocity in the portal vein and left portal branch. The best US-Doppler parameter to appraise the paraumbilical vein influence upon the portal system is the mean flow velocity. The correlation between the increase in portal veins mean flow velocity is stronger with the paraumbilical veins mean flow velocity than with its diameter. The increase in the portal veins and left portal branchs mean flow velocity may be understood as the paraumbilical veins hemodynamic influence upon the portal system. An active portosystemic collateral pathway increases the mean flow velocity in the veins segment proximal to its point of origin.BACKGROUNDnThe hemodynamical effect of the collateral portosystemic circulation upon the portal system has not yet been fully understood. The US-Doppler made possible the non-invasive study of the portal system by evaluating the parameters: flow direction, diameter and flow velocity in its vessels.nnnAIMSnTo study the paraumbilical vein as a collateral portosystemic pathway and identify patterns for appraising its hemodynamic importance to the portal system.nnnMETHODnUS-Doppler study of the portal system of 24 patients with Mansonis hepatosplenic schistosomic portal hypertension, previous esophagic variceal bleeding and patent paraumbilical vein with hepatofugal flow. The diameter and the mean flow velocity were measured in the paraumbilical vein and so were the mean flow velocity in the portal vein, right and left portal branches. The Pearson test (linear correlation) was applied to the portal veins mean flow velocity and the paraumbilical veins diameter and mean flow velocity. The patients were divided in four groups: D1-paraumbilical vein with diameter < 0.68 cm (n = 14), D2-paraumbilical vein with diameter > or = 0.68 cm (n = 10), V1-paraumbilical vein with mean flow velocity < 18.41 cm/seg (n = 13) and V2-paraumbilical vein with mean flow velocity > or = 18.41 cm/seg (n = 11). The mean flow velocity in the portal vein, right and left portal branches of the four groups were compared.nnnRESULTSnThe paraumbilical vein diameter was 0.68 +/- 0.33 cm (range: 0.15-1.30 cm) and the mean flow velocity was 18.41 +/- 11.51 cm/seg (range: 5.73-38.20 cm/seg). The linear correlation between the portal veins mean flow velocity/paraumbilical vein diameter and the paraumbilical veins mean flow velocity showed r = 0.504 and r = 0.735, respectively. In the group D2 there was an increase in the mean flow velocity in the portal vein (17.80 +/- 3.42/22.30 +/- 7.67 cm/seg) and in the left portal branch (16.00 +/- 4.73/22.40 +/- 7.90 cm/seg). In the group V2 there was an increase in the mean flow velocity in the portal vein (16.31 +/- 3.49/21.96 +/- 5.89 cm/seg) and in the left portal branch (14.22 +/- 4.41/21.94 +/- 7.20 cm/seg). There was no change in the right portal branch (13.67 +/- 5.74/15.43 +/- 3.43 cm/seg).nnnCONCLUSIONSnIn portal hypertension due to hepatosplenic schistosomiasis, the patent paraumbilical vein, with hepatofugal flow, diameter > or = 0.68 cm and mean flow velocity > or = 18.41 cm/seg causes an increase of the mean flow velocity in the portal vein and left portal branch. The best US-Doppler parameter to appraise the paraumbilical vein influence upon the portal system is the mean flow velocity. The correlation between the increase in portal veins mean flow velocity is stronger with the paraumbilical veins mean flow velocity than with its diameter. The increase in the portal veins and left portal branchs mean flow velocity may be understood as the paraumbilical veins hemodynamic influence upon the portal system. An active portosystemic collateral pathway increases the mean flow velocity in the veins segment proximal to its point of origin.

Grandes hérnias incisionais

INTRODUCAO: A correcao de hernias incisionais abdominais permanece como um dos procedimentos cirurgicos mais comuns uma vez que ela ocorre em cerca de 11% das laparotomias. Varios sao os fatores de risco. Surgem, em geral, nos primeiros cinco anos apos a operacao e seu manuseio ainda e controverso. OBJETIVO: Atualizar os meios e metodos empregados para a correcao cirurgica das hernias abdominais gigantes. METODO: Revisao da literatura com base no Pubmed, Scielo e Lilacs com cruzamento dos descritores hernia abdominal, proteses, complicacoes e tecnicas cirurgicas, e adicionando contribuicao propria baseada na experiencia dos autores no manuseio desta afeccao. CONCLUSAO: Mesmo as correcoes bem sucedidas, com a utilizacao ou nao de grandes proteses, nao sao os procedimentos isentos de inconvenientes, pois a parede abdominal nao retoma a sua elasticidade e complacencia normais. Por este motivo, e importante que o paciente seja alertado da possibilidade da sua expectativa em relacao ao resultado, tanto estetico quanto funcional, nao ser alcancada.

Lower eyelid repair utilising triangular skin flaps with subcutaneous pedicles

Fifty-four patients were studied during the period from 1984 to 1989. The lower eyelid was repaired in 55 cases utilising a triangular flap with a subcutaneous pedicle. Repair was achieved in 39 cases with a triangular flap only and in 16 it was necessary to use a chondromucosal graft of nasal septum as well. The method is described and is feasible for repairs ranging from the simplest to the most complex in different locations of the lid.

Late morphologic and hemodynamic changes in the splenic territory of patients with mansoni's hepatosplenic schistosomiasis after distal splenorenal shunt. (Ultrasonography-Doppler study)

BACKGROUNDnThe distal splenorenal anastomosis (Warrens operation) has been indicated for the treatment of high digestive bleeding caused by esophagic varices because it would ideally reduce the venous pressure in the cardiotuberositary territory without changing the mesenteric-portal venous flow. However, the changes it produce in the splenic territory have not been fully understood.nnnAIMnTo appraise the late morphologic and hemodynamic changes in the splenic territory produced by the distal splenorenal anastomosis in patients with portal hypertension due to mansonis hepatosplenic schistosomiasis complicated by esophagic bleeding.nnnMETHODnUltrasonography-Doppler study of the splenic region of 52 patients with portal hypertension due to mansonis schistosomiasis and previous bleeding by esophagic varices. They were divided in two groups: 40 non operated upon and 12 with a distal splenorerenal anastomosis. The following parameters and indices were compared between the two groups: a) morphometric parameters (splenic artery and veins diameter, splenic diameters (longitudinal, transversal and antero-posterior); b) velocimetric parameters of the splenic vessels (systolic peak velocity in the splenic artery, mean flow velocity in the splenic vein; c) biometric index of the spleen (longitudinal x transversal); volumetric index of the spleen (longitudinal x transversal x antero-posterior x 0,523); hemodynamic indices of the splenic arterys impedance: pulsatility and resistivity.nnnRESULTSnThe patients with distal splenorenal anastomosis showed: a) reduction in splenic indices: volumetric (non operated 903,83 +/- 452, 77 cm / distal splenorenal anastomosis 482,32 +/- 208,02 cm (46,64%)) and biometric (non operated 138,14 +/- 51,89 cm /distal splenorenal anastomosis 94,83 +/- 39,83 cm (33,35%)); b) no change: splenic arterys diameter (non operated 0,57 +/- 0,16 cm/distal splenorenal anastomosis 0,57 +/- 0,23 cm); velocity in the splenic artery non operated 107 +/- 42,02 cm/seg/distal splenorenal anastomosis 89,81 +/- 41,20 cm/seg), resistivity (non operated 0,58 +/- 0,008/distal splenorenal anastomosis 0,56 +/- 0,06) and pulsatility (non operated 0,91 +/- 0,19/distal splenorenal anastomosis 0,86 +/- 0,15, splenic vein (non operated 1,10 +/- 0,30 cm/distal splenorenal anastomosis 1,19 +/- 0,29 cm); c) increase: mean flow velocity in the splenic vein (non operated 20,54 +/- 8,45 cm/seg/distal splenorenal anastomosis 27,83 +/- 9,29 cm/seg).nnnCONCLUSIONSnThe comparison of the ultrasonography Doppler results of the two groups of patient (non operated and distal splenorenal anastomosis) showed that in patients with distal splenorenal anastomosis there was a decrease of the volume of spleen; increase in the mean flow velocity in the splenic vein; no changes in the morphologic and hemodinamyc parameters of the splenic artery neither in its velocimetric indices.