Manlio Basilio Speranzini

Perianal diseases in HIV-positive patients compared with a seronegative population.

PURPOSE: The aim of this report was to present our cases showing the prevalence and cause of perianal diseases in human immunodeficiency virus-positive patients. METHODS: We compared 1,860 human immunodeficiency virus-positive patients to 1,350 human immunodeficiency virus-negative outpatients with perianal diseases, examined from January 1989 to December 1996, and the results obtained with the treatment methods for seropositive patients. Among them, 88.7 percent were males, mostly in the age range from 30 to 50 years old. RESULTS: Condylomas, ulcers, hemorrhoids, fistulas, fissures, abscesses, and tumors were the most frequently diagnosed diseases. Two or more anal diseases occurred in 16.7 percent of patients. Among the human immunodeficiency virus-negative patients we noticed the same incidence of gender, and most were in the age range of 40 to 60 years old. Hemorrhoids, fistulas, skin tags, and fissures were diagnosed. CONCLUSIONS: From statistical analysis we may conclude that human immunodeficiency virus-positive patients have more condylomas, ulcers, tumors, fistulas, and abscesses than human immunodeficiency virus-negative patients, who have more hemorrhoids. Incidence of fissures was similar in the two groups.

Healing after anal fistulotomy

PURPOSE: The aim of this work was to compare wound-healing after anal fistulotomy in human immunodeficiency virus (HIV)+ and HIV− patients and to recognize healing parameters in HIV+ patients. METHODS: Sixty patients were treated with fistulotomy for intersphincteric anal fistula. For each patient, we evaluated white blood cell count values, T CD4 counts, Centers for Disease Control and Prevention classification, and healing duration. There were 31 HIV+ patients (7 A2; 1 A3; 7 C1; 6 C2; 10 C3). RESULTS: Seven C3 patients had incomplete healing. Statistically, there was no difference in the healing duration in HIV+ A2, C1, C2, and HIV-negative patients. C3 patients who did heal took longer than other HIV+ patients. T CD4 counts were similar to healed and not healed C3 patients, although healed C3 values of white blood cell counts were higher than not healed C3 values (4,450 and 2,380/mm3). CONCLUSION: After anal fistulotomy, HIV+ C3 patients either had retarded healing or no healing at all. Therefore, we feel that surgery should be done only in emergency cases of anorectal diseases or in patients with more than 3,000 white blood cells/mm3.

Bacteriology of the anal wound after open hemorrhoidectomy

The purpose of this study is to analyze the size of the bacterial colonies in anal wounds after open hemorrhoidectomy. Twenty patients were studied during predetermined postoperative time periods. Material was collected from the surface and from within the tissue of each patients three open wounds, intraoperatively, on the 6th, 13th and 20th postoperative days for bacteriologic examination in aerobic, microaerophilic, and anaerobic media. The bacterium most commonly identified wasEscherichia coli,followed byStaphylococcus aureusandStaphylococcus epidermidis. Pseudomonas aeruginosa, Enterococcus faecalis, Klebsiella pneumoniae, Proteus vulgaris,andProteus mirabiliswere also identified. Critical indexes of colonization were present since the intraoperative stage (>105bacteria/g of tissue and >106bacteria/ml); obligate anaerobic bacteria were not identified; neither the species nor the number of bacteria, even when critical indexes were present, prevented proper healing. The same bacteria were not necessarily present on the surface and in the tissue; the bacterial load observed among the three wounds (left lateral, right posterior, and right anterior), was the same.

Why Do Anal Wounds Heal Adequately? A Study of the Local Immunoinflammatory Defense Mechanisms

PURPOSEThe aim of this study was to identify the tissue defense immunoinflammatory mechanisms present in the healing process of anal region wounds resulting from hemorrhoidectomy by the open technique.METHODSImmunohistochemical techniques were applied to biopsies of anal wounds obtained on Day 0 and Day 6 after surgery from 20 patients with hemorrhoid disease to characterize and quantify macrophages, T and B lymphocytes, and natural killer cells in high-power fields (400×). These techniques were also used to identify cells showing immunoexpression of cytokines (transforming growth factor beta 1, transforming growth factor beta 2, transforming growth factor beta 3) and constitutive and induced nitric oxide synthase. Plasma cells were quantified on slides stained with hematoxylin and eosin and the presence of immunoglobulin G, immunoglobulin M, and immunoglobulin A secreting cells was investigated by direct immunofluorescence.RESULTSAn acute nonspecific inflammation with no lymphomononuclear-plasmacytic component was observed on Day 0. On Day 6, an inflammatory cellular infiltration rich in macrophages and lymphoplasmacytic cells was detected, which documented the participation of innate defense mechanisms and the adaptive tissue response. On Day 6, the mean number of immunoinflammatory cells were as follows: macrophages (CD68+) = 190.3; macrophages (HAM56+) = 184.3; T lymphocytes (CD3+) = 59.6; T lymphocytes (CD45RO+) = 47.7; helper T lymphocytes (CD4+) = 89.2; cytotoxic T lymphocytes (CD8+) = 29.4; B lymphocytes (CD20+) = 64.4; plasma cells = 1.7; natural killer cells (NK1+) = 12.9. Macrophages (HAM56+ and CD68+) were present in significantly higher amounts than those of the remaining ones. B lymphocytes (CD20+) predominated over T lymphocytes (CD3+), although the difference between the two cell types was not significant. Participation of the humoral immune system was characterized by the presence of immunoglobulin G–secreting cells. The cellular immune system was characterized by the identification of T lymphocytes (CD3+ and CD45RO+), most of them belonging to the T helper cell subpopulation (CD4+). These predominated in a significant manner over cytotoxic T lymphocytes (CD8+). Natural killer cells were present in small amounts. There was immunoexpression of constitutive nitric oxide synthase on Day 0 and on Day 6. Induced nitric oxide synthase was not identified on Day 0 but was present on Day 6. Transforming growth factor beta 2 and transforming growth factor beta 3 were expressed in endothelial cells on Day 0 and on Day 6, and transforming growth factor beta1 was also expressed in macrophages, endothelial cells, and fibroblasts on Day 6. Transforming growth factor beta 1 and transforming growth factor beta 2 were expressed significantly in macrophages, whereas transforming growth factor beta 3 occurred at similar proportions in the three cell types.CONCLUSIONSThe host developed locally innate and immunologic defense adaptive mechanisms. The predominant local defense response involved macrophages. Natural killer cells and immunoexpression of constitutive nitric oxide synthase in endothelial cells were components of the noninduced innate response. In the induced innate response, in addition to neutrophils, there were large numbers of macrophages that were the major cells showing immunoexpression of transforming growth factor beta and induced nitric oxide synthase. The adaptive immunologic response was characterized by T and B lymphocytes. Helper T cells and cytotoxic T cells predominated in the cellular immune response and cytotoxic T cells and natural killer cells were present in small numbers. Secretory immunoglobulin G plasma cells were present in small numbers as a component of the humoral immune system.

Estudo comparativo entre as anastomoses cervicais esofagogástrica término-terminal com e sem invaginação após esofagectomia para câncer

OBJECTIVE To assess the incidence of fistula and stenosis of cervical esophagogastric anastomosis with invagination of the esophageal stump into the gastric tube in esophagectomy for esophagus cancer. METHODS Two groups of patients with thoracic and abdominal esophagus cancer undergoing esophagectomy and esophagogastroplasty were studied. Group I comprised 29 patients who underwent cervical esophagogastric anastomosis with invagination of the proximal esophageal stump segment within the stomach, in the period of 1998 to 2007 while Group II was composed of 36 patients submitted to end-to-end cervical esophago-gastric anastomosis without invagination during the period of 1989 to 1997. RESULTS In Group I, esophagogastric anastomosis by invagination presented fistula with mild clinical implications in 3 (10.3%) patients, whereas in Group II, fistulas with heavy saliva leaks were observed in 11 (30.5%) patients. The frequency of fistulas was significantly lower in Group I patients (p=0.04) than in Group II. In Group I, fibrotic stenosis of anastomoses occurred in 7 (24.1%) subjects, and 10 patients (27.7%) in Group II evolved with stenosis, while no significant difference (p=0.72) was found between the two groups. CONCLUSION In esophagectomy for esophagus cancer, cervical esophagogastric anastomosis with invagination presented a lower rate of esophagogastric fistula versus anastomosis without invagination. Stenosis rates in esophagogastric anastomosis proved similar in both approach with or without invagination.

En-bloc pancreatoduodenectomy and right hemicolectomy for treating locally advanced right colon cancer (T4): a series of five patients

A series of five cases of right-colon adenocarcinoma that invaded the proximal duodenum is presented. All patients underwent successful en-bloc pancreatoduodenectomy plus right hemicolectomy by General Surgery Service of the Teaching Hospital of the ABC Medical School, Santo André, SP, Brazil. The study was conducted between 2000 and 2007. There were two major complications but no mortality. Three patients did not present any recurrence over the course of 15 to 54 months of follow-up. Multivisceral resection with en-bloc pancreatoduodenectomy should be considered for patients who are fit for major surgery but do not present distant dissemination. Long-term survival may be attained.

Doença de Crohn isolada do apêndice cecal como causa de enterorragia

BACKGROUND Crohns disease confined to the appendix is relatively rare as a sole primary manifestation of the disease. Young people are more affected. The medical history and the physical examination are similar to the findings in acute appendicitis, but the manifestations are protracted. On physical examination there are signs of peritoneal irritation and an abdominal mass is palpable in the right iliac fossa. AIMS To report a case of Crohns disease confined to the appendix and presenting with enterorrhagia. The source of the bleeding was localized by colonoscopy. PATIENT A 16-year old caucasian male without past history of gastrointestinal symptoms, presented with two episodes of enterorrhagia within a period of one year. In the second episode colonoscopy identified the appendicular ostium as the source of bleeding. RESULTS At operation the cecum and terminal ileum were normal in thickness and texture, and an inflammatory appendix adherent to the omentum was removed. Microscopically there were non-caseating granulomas, intense infiltration of the wall with plasma cells, lymphocytes and macrophages. The patient has not suffered recurrence, and a colonoscopy realized 2 years after the operation did not show signs of Crohns disease. CONCLUSION This case, like others in the literature, appendectomy is curative, but a 5-year follow-up is mandatory. When a young patient presents with enterorrhagia, this diagnosis has to be considered.

Apendicite aguda: modelo experimental em coelhos

The evolving phases of acute appendicitis were studied experimentally. Sixty female rabbits (Oryctogalus cuniculus) of New Zealand lineage weighing about 2510 to 3040 g were divided in two groups: a control group and experimental group. The experimental group was divided into three subgroups for observation after 12, 24 and 48 hours of the operation, that consisted on a 4-0 polypropylene circular suture at 8 cm from the distal part of the cecal appendix. The control group was sham operated. The macroscopic exam (increase of the appendix volume, necrosis, perfuration, adherence and secretion in the abdominal cavity) and the microscopic finding showed a progression in the anatomopathological alterations. There was a close relationship between the histopathological findings and time after the appendiceal obstruction. We conclude that the method causes acute appendicitis and that the anathomo pathological alterations depends on the time elapsed between the operation and the postoperation findings.The evolving phases of acute appendicitis were studied experimentally. Sixty female rabbits (Oryctogalus cuniculus) of New Zealand lineage weighing about 2510 to 3040 g were divided in two groups: a control group and experimental group. The experimental group was divided into three subgroups for observation after 12, 24 and 48 hours of the operation, that consisted on a 4-0 polypropylene circular suture at 8 cm from the distal part of the cecal appendix. The control group was sham operated. The macroscopic exam (increase of the appendix volume, necrosis, perfuration, adherence and secretion in the abdominal cavity) and the microscopic finding showed a progression in the anatomopathological alterations. There was a close relationship between the histopathological findings and time after the appendiceal obstruction. We conclude that the method causes acute appendicitis and that the anathomo pathological alterations depends on the time elapsed between the operation and the postoperation findings.

Feasibility analysis of loop colostomy closure in patients under local anesthesia

PURPOSE To verify prospectively the practicability of performing loop colostomy closure under local anesthesia and sedation. METHODS In this study, 21 patients underwent this operation. Lidocaine 2% and bupivacaine 0.5% were utilized. Pain was evaluated during the operation, on the first postoperative day and at hospital discharge. Intraoperative events, postoperative complications and the acceptability of this procedure were analyzed. RESULTS The mean duration of the operation was 133 minutes (range: 85 to 290 minutes). The mean postoperative hospitalization was four days (range: one to twelve days). No patients died. Complications occurred in two patients (9.4%): abdominal wall hematoma and operative wound infection. With regard to pain severity, scores of less than or equal to three were indicated in the intraoperative evaluation by 80% of the patients (17/21) and on the first postoperative day by 85% (18/21). At hospital discharge, 95.2% of the patients (20/21) said they were in favor of the local anesthesia technique. CONCLUSION Loop colostomy closure under local anesthesia and sedation is feasible, safe and acceptable to patients.

Ampullary duodenal diverticulum and cholangitis

CONTEXT Ampullary duodenal diverticulum complicated by cholangitis is little known in clinical practice, especially when there are no gallstones in the common bile duct or there is no biliary tree ectasia or hyperamylasemia. A case of this association is presented, in which the surgical treatment was a biliary-enteric bypass. CASE REPORT A 74-year-old diabetic white woman was admitted to the Taubat University Hospital, complaining of pain in the right upper quadrant, jaundice and fever with chills (Charcots triad). She had had cholecystectomy 30 years earlier. She underwent clinical treatment with parenteral hydration, insulin, antibiotics and symptomatic drugs. Imaging examinations were provided for diagnosis: ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography. The surgical treatment consisted of choledochojejunostomy utilizing a Roux-en-y loop. The postoperative period progressed without incidents, and a DISIDA scan demonstrated the presence of dynamic biliary excretion. The patient remained asymptomatic when seen at outpatient follow-up.