Paulo Roberto Corsi

Trauma in pregnant women: analysis of maternal and fetal mortality

Twenty-seven traumatised pregnant women were analysed retrospectively over a period of 9 years. Mean age was 23.7 years (16-42 years). Gestational age ranged from 10 to 40 weeks (mean, 21.5 weeks), with most victims (46.1%) being in the second trimester. The predominant mechanism (65.3%) was blunt abdominal injury due to an automobile accident (the patient being run over or collision). At admission, 8 (30.7%) patients had haemodynamic alterations. 6 patients (23.0%) presented vaginal bleeding and 4 of these were haemodynamically normal. We analysed maternal mortality, fetal mortality and their causes. We also compared the median RTS and TRISS values for the groups with maternal-fetal survival and the group with maternal-fetal death. Fetal death occurred in all pregnant women admitted with vaginal bleeding. Maternal mortality due to haemorrhagic shock was 11.5%. Fetal mortality was 30.7%, with 37.5% of these deaths being caused by maternal death. The major cause of fetal mortality was a detached placenta (50.0%). The trauma indices, RTS and TRISS, were significantly lower (p = 0.0025 and p < 0.0001) in the group of maternal-fetal death but they were not of prognostic value in terms of fetal mortality.

Câncer do esôfago: complicações pós-operatórias imediatas e letalidade hospitalar

OBJECTIVE: The analysis of the variables that can influence on the immediate postoperative complications and hospital mortality of patients with esophageal cancer submitted to surgery. METHODS: In a retrospective analysis of data from 60 patients, variables such as provenience, disease history, previous diseases, smoking, alcohol drinking, disease stage, and the nature of the surgery were studied in order to check if they could have played a role on complications and death. RESULTS: The resulting variables: pleuropulmonary complications, sepsis, dehiscence of cervical anastomosis, mediastinitis, and death have been more significantly correlated to the following explanatory variables, respectively: palliative surgery, mediastinitis, tumor located in the superior thoracic segment, and sepsis. By means of univaried analysis, the explanatory variables have showed no significant correlation with dehiscence of thoracic anastomosis. Palliative surgery and respiratory insufficiency were the explanatory variables more significantly associated to the resulting variable pleuropulmonary complications. The interdependence of these variables has allowed to state that pleuropulmonary complications were 13.8 times more frequent in the patients with esophageal cancer submitted to palliative surgery developing respiratory insufficiency. CONCLUSION: Palliative surgery and tumor located in the superior segment have correlated to pleuropulmonary complications. There was no correlation at all between the variables here studied and dehiscence of intrathoracic anastomosis.

Presença de refluxo em pacientes com sintomas típicos de doença do refluxo gastroesofágico

OBJECTIVE: To analyze clinical, abdominal ultrasound, upper digestive endoscopic, esophageal manometric and prolonged esophageal pH-monitoring findings in patients with typical symptoms of GERD. METHODS: The study included a total of 251 patients with typical GERD symptoms. Clinical data, Body Mass Index, abdominal ultrasound aspects and upper digestive endoscopic data are reported. Manometry and esophageal pH-monitoring were performed. RESULTS: One-hundred-and-seventy-two patients were female (68.5%). Mean age of the total was 51.8 years. Ultrasound examination revealed colelithiasis in 23 patients and PC in 21 patients. Hiatal hernia was diagnosed in 177 patients (71%), with an average size of 3.0cm. Erosive esophagitis was found in 168 patients (66.9%) and Barretts esophagus in 23 patients (9.2%). A combination of hiatal hernia and esophagitis was diagnosed in 131 patients (52.3%) while only 37 patients (14.7%) did not present either. The mean extension of the lower esophageal sphincter (LES) was 2.6 cm, whereas in 132 patients (52.6%) the LES was shorter. The mean pressure of the LES was 18.9 mmHg; 46 patients (18.3%) had pressures below 14 mmHg. The mean number of reflux episodes on prolonged esophageal monitoring was 42.9; the mean number of prolonged episodes of reflux was 4.6, and the mean percentage of total acid time was 8.4%. DeMeester scores were high in 175 patients (69.7%). CONCLUSION: In patients with typical GERD symptoms, factors influencing the presence of pathological reflux as confirmed by prolonged esophageal pH-monitoring were: age, hiatal hernia associated to erosive esophagitis, a smaller extension, low baseline pressure and smaller volume vector of the LES.

Lesão aguda esôfago - gástrica causada por agente químico

UNLABELLED Treatment of chemical agent ingestion remain controversial. The incidence of these episodes has increased over the several last decades due to a variety reasons. PURPOSE To analyze the occurrence, complications and results of the treatment of chemically induced esophagogastric injury. METHODS Twenty-one adult patients with chemically induced esophagogastric injury were retrospectively studied. The patients were admitted up to 23 days after ingestion of a chemical agent to the Emergency Department of Santa Casa of Sao Paulo University Hospital from August, in a 12-year period. The mean age was 32.1 years. Eleven patients were of the female gender, which attempted suicide. Soda was the most ingested agent (76.2%), muriatic acid was present in three cases (14.3%) followed by one case of sulfur acid and another one of ammonia (4.8% each). RESULTS Injuries of the Larynx and Pharynx were frequently associated with those of the esophagus, accounting for 18 cases (85.7%). Esophageal, gastric and duodenal injuries were assessed and classified according to endoscopic features. Five cases each of severe esophageal or gastric lesions were present. CONCLUSION Treatment and outcome varied and suggested placement of esophageal tube to be harmful. Global mortality rate was 28.6% with the highest rate related to esophageal injuries of the third degree.O tratamento da ingestao de agentes quimicos corrosivos continua controverso. A incidencia desses episodios tem aumentado nas ultimas decadas por varias razoes. OBJETIVO: Analisar a ocorrencia, as complicacoes e os resultados do tratamento da lesao esofago - gastrica causada por agentes quimicos. METODOS: Foram estudados retrospectivamente 21 pacientes adultos com lesao esofago-gastrica, causada por ingestao de substância quimica, admitidos ate 23 dias apos o episodio, no Servico de Emergencia da Santa Casa de Misericordia de Sao Paulo num periodo de 12 anos. A media de idade foi 32,1 anos e 11 doentes pertenciam ao sexo feminino, as quais mais frequentemente tinham intencoes suicidas. A soda caustica foi o produto mais ingerido (76,2%), ingestao de acido muriatico ocorreu em tres casos (14,3%), amoniaco e acido sulfurico em um caso (4,8%) cada. RESULTADOS: As lesoes faringeas e laringeas estiveram frequentemente associadas as lesoes de esofago, presentes em 18 casos (85,7%). As lesoes esofagicas, gastricas e duodenais foram avaliadas e classificadas por endoscopia. Lesoes graves esofagicas ou gastricas estiveram presentes em cinco casos cada. CONCLUSAO: O tratamento e os resultados foram variados, mas sugeriram que a sondagem esofagica foi prejudicial. A mortalidade global foi 28,6%, mais elevada na lesao esofagica grau 3.

Treatment of transfixing hepatic lesions with a hydrostatic balloon

Os autores analisaram 13 doentes com ferimentos hepatico transfixante tratados com a colocacao de balao hidrostatico no trajeto do ferimento. Cinco doentes apresentavam ferimento abdominal exclusivo, enquanto 8 eram toraco-abdominais. Em todos os casos houve acometimento do lobo direito e em tres o acometimento foi bilobar. O tempo medio de permanencia do balao insuflado foi de 9 dias. Dois doentes necessitavam reoperacao para a retirada do balao em virtude de existencia de aderencias que impediam sua mobilizacao. Nao foram observados casos de sangramento apos a retirada do balao. A permanencia hospitalar variou de 5 a 36 dias. Sao discutidas as indicacoes e as vantagens da colocacao desse tipo de dispositivo em doentes com ferimentos hepaticos profundos, transfixantes e com sangramento abundante.

Tratamento cirúrgico das complicações da anastomose esôfago-visceral cervical

A anastomose esofago-visceral cervical apresenta como complicacoes a fistula e a estenose, que podem necessitar de reintervencao cirurgica para sua correcao. Com o objetivo de avaliar as taticas para abordagem operatoria dessas complicacoes e seus resultados, os autores estudaram retrospectivamente nove pacientes, que demandaram esta conduta, num periodo de 17 anos. Foram operadas duas fistulas e sete estenoses da anastomose esofago-visceral cervical, sendo a via de acesso inicial a cervicotomia em todos os pacientes. Em quatro casos, houve necessidade de ampliacao para esternotomia mediana total, que facilitou significativamente a reconstrucao, porem com mortalidade de 75%. As taticas adotadas foram a reanastomose em cinco casos, a sutura do orificio da fistula em um caso e a plastia em tres casos. A ressutura teve mau resultado. As plastias evoluiram satisfatoriamente, e os doentes submetidos a reanastomose sem esternotomia tambem evoluiram satisfatoriamente. A plastia da anastomose demonstrou ser uma boa tatica para o tratamento da estenose cervical, enquanto a reanastomose parece ter a melhor indicacao nas fistulas, devendo-se evitar a esternotomia total mediana.

Trauma na gestante: análise da mortalidade materna e fetal

Foram analisadas retrospectivamente 26 pacientes gestantes traumatizadas, num periodo de nove anos. A media de idade foi 23,7 anos (16-42). A idade gestacional variou de dez a quarenta semanas (media 21,5 semanas); a maioria (46,1%) no segundo trimestre. O mecanismo predominante (65,3%) foi o trauma abdominal fechado por acidente automobilistico (atropelamento ou colisao). Na admissao, oito (30,7%) pacientes apresentavam alteracoes hemodinâmicas. Seis doentes (23,0%) apresentavam sangramento vaginal e, destas, quatro estavam hemodinamicamente normais. Analisamos a mortalidade materna, a mortalidade fetal e suas causas. Comparamos tambem a mediana dos valores do RTS e TRISS entre os grupos, sobrevida materno-fetal, sobrevida materna e obito materno-fetal. Todas as gestantes admitidas com sangramento vaginal apresentaram obito fetal. A mortalidade materna foi de 11,5%, por choque hemorragico. A mortalidade fetal foi de 30,7%, sendo que 37,5% destes obitos foram provocados pela morte materna. A principal causa de mortalidade fetal foi o descolamento de placenta (50,0%). Os indices de trauma, RTS e TRISS, foram significativamente menor (p=0,0025 e p<0,0001) no grupo obito materno-fetal, porem esses indices nao apresentaram valor prognostico na mortalidade fetal.

Complicações imediatas do tratamento cirúrgico da doença do refluxo gastroesofágico pela técnica de Toupet

Num periodo de 12 anos, de julho de 1984 a junho de 1996, 120 pacientes portadores de doenca do refluxo gastroesofagico foram submetidos a cirurgia anti-refluxo pela tecnica de Toupet. A media de idade foi 52,4 anos e 72 (60%) eram do sexo feminino. Do total de doentes, 74 (61,7%) apresentavam doenca clinica associada e/ou vicio. Oito pacientes ja haviam realizado cirurgia previa para correcao de doenca do refluxo gastroesofagico, com recidiva dos sintomas. Os acidentes operatorios foram lesao esplenica (seis casos), lesao de esofago, pleura, figado e veia porta, que ocorreram, isoladamente, em quatro pacientes. A letalidade hospitalar foi 6,6% porem, nao houve obito intra-operatorio. Complicacoes pos-operatorias imediatas ocorreram em 27 (22,5%) dos doentes. A analise univariada mostrou que foram significantes para o aparecimento de complicacoes as variaveis: idade, tabagismo, alcoolismo, lesao de baco e reoperacao. Para letalidade foram significantes apenas: idade e reoperacao. A analise multivariada confirmou a significância apenas da variavel reoperacao no aparecimento de complicacoes pos-operatorias e na letalidade.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

OBJECTIVE to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. METHODS review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. RESULTS the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. CONCLUSION this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.

Esophagectomy with gastroplasty in advanced megaesophagus: late results of omeprazole use.

OBJECTIVE To analyze the late results of advanced Chagasic megaesophagus treatment by esophagectomy associated with the use of proton pump inhibitor (omeprazole) as for the incidence of esophagitis and Barretts esophagus in the remaining stump. METHODS We studied patients with advanced megaesophagus undergoing esophagectomy and transmediastinal esophagogastroplasty. Patients were divided into three groups: A (20) with esophageal replacement by full stomach, without the use of omeprazole; B (20) with esophageal replacement by full stomach, with omeprazole 40 mg/day introduced after the first postoperative endoscopy and maintained for six years; and C (30) with esophageal replacement by gastric tube with use of omeprazole. Dysphagia, weight loss and BMI were clinical parameters we analyzed. Upper gastrointestinal endoscopy was performed in all patients, and determined the height of the anastomosis, the aspect of the mucosa, with special attention to possible injuries arising from gastroesophageal reflux, and the patency of the esophagogastric anastomosis. RESULTS We studied 50 patients, 28 males (56%) and 22 (44%) females. All underwent endoscopy every year. In the first endoscopy, erosive esophagitis was present in nine patients (18%) and Barretts esophagus, in four (8%); in the last endoscopy, erosive esophagitis was present in five patients (8%) and Barretts esophagus in one (2%). When comparing groups B and C, there was no evidence that the manufacturing of a gastric tube reduced esophagitis and Barretts esophagus. However, when comparing groups A and C, omeprazole use was correlated with reduction of reflux complications such as esophagitis and Barretts esophagus (p <0.005). CONCLUSION The use of omeprazole (40 mg/day) reduced the onset of erosive esophagitis and Barretts esophagus during the late postoperative period.