Ramiro Colleoni

Laparoscopy predicts metastatic disease and spares laparotomy in selected patients with pancreatic nonfunctioning islet cell tumors.

Introduction: Our objective was to compare the efficacy of CT alone to CT followed by laparoscopy in determining resectability of pancreatic nonfunctioning islet (NFI) cell tumors.Methods: A retrospective analysis from 1993 to 1999 revealed 48 patients who underwent surgical evaluation for NFI cell tumors. Of these, 34 (71%) patients underwent laparoscopy and CT for either diagnostic purposes or tumor staging. CT and laparoscopic criteria for curative resectability were defined and the sensitivity, specificity, and predictive value of both modalities in determining resectability were calculated.Results: The most frequent tumor location and presenting symptoms were pancreatic head (n = 27, 56%) and abdominal pain (n = 31, 65%), respectively. Median tumor size was 4.0 cm. In the laparoscopy group, curative resection was performed in 20 cases (59%). CT followed by laparoscopy was more sensitive than CT alone in predicting resectability (93% vs. 50%, P = 0.03) with similar specificity (both 100%). The predictive value for tumor resectability was 74% for CT alone and 95% for CT followed by laparoscopy. Reasons for unresectability identified at laparoscopy but not indicated by CT were liver metastases (n = 6) or nodal disease (n = 1). Four of these patients were spared a laparotomy while the other three patients underwent surgical palliation and all are alive with disease (AWD). In those not undergoing laparoscopy (n = 14), curative resection was performed in 64% (n = 9). Four of these patients underwent resection, despite having metastases, and three are AWD.Conclusions: NFI cell tumors of the pancreas present as large masses with frequent metastases. Despite metastatic disease, prolonged survival is often achieved with or without open surgical treatment. Laparoscopy can be used in diagnosis and accurately identifies metastases not seen on CT, thus sparing laparotomy in some patients.

Avaliação ultra-sonográfica de nódulos sideróticos esplênicos em pacientes esquistossomóticos com hipertensão portal

OBJETIVO: Medir a sensibilidade e a reprodutibilidade da ultra-sonografia na deteccao de nodulos sideroticos esplenicos em pacientes esquistossomoticos, tendo a ressonância magnetica como padrao de referencia. MATERIAIS E METODOS: Na primeira fase do trabalho, 21 pacientes portadores de esquistossomose na forma hepatoesplenica com diagnostico de nodulos sideroticos a ressonância magnetica foram submetidos a avaliacao ultra-sonografica para a determinacao da sensibilidade do metodo. Na segunda fase, com o objetivo de avaliar a reprodutibilidade da ultra-sonografia na deteccao e na quantificacao de nodulos sideroticos (A: 1-5 nodulos; B: 6-20 nodulos; C: mais de 20 nodulos), outros 30 pacientes esquistossomoticos foram submetidos a avaliacao ultra-sonografica de forma cega e independente por dois observadores. A reprodutibilidade foi medida por meio da concordância entre os observadores e do teste kappa. RESULTADOS: A sensibilidade da ultra-sonografia foi de 95,2% (intervalo de confianca a 95% [77,3%; 99,2%]). A concordância entre ultra-sonografia e ressonância magnetica para a deteccao de nodulos sideroticos foi de 96,7% (intervalo de confianca a 95% [82,8%; 99,9%]). Para a classificacao dos nodulos conforme a sua quantificacao, o indice kappa demonstrou concordância interobservador substancial (kappa = 0,67). CONCLUSAO: A ultra-sonografia e um metodo que apresenta elevada sensibilidade e boa precisao para a avaliacao de nodulos sideroticos esplenicos.

Mensuração do volume de fluxo portal em pacientes esquistossomóticos: avaliação da reprodutibilidade do ultra-som Doppler

OBJECTIVE: To evaluate the reproducibility of Doppler ultrasonography in the measurement of portal blood flow volume in schistosomal patients. MATERIALS AND METHODOS: Prospective, transversal, observational and self-paired study evaluating 21 patients with hepatosplenic schistosomiasis submitted to Doppler ultrasonography performed by three independent observers for measurement of portal blood flow. Pairwise interobserver agreement was calculated by means of the intraclass correlation coefficient, paired t-test and Pearsons correlation coefficient. RESULTS: Interobserver agreement was excellent. Intraclass correlation ranged from 80.6% to 93.0% (IC at 95% [65.3% ; 95.8%]), with the Pearsons correlation coefficient ranging between 81.6% and 92.7% with no statistically significant interobserver difference regarding the mean portal blood flow volume measured by Doppler ultrasonography (p = 0.954 / 0.758 / 0.749). CONCLUSION: Doppler ultrasonography has demonstrated to be a reliable method for measuring the portal blood flow volume in patients with portal hypertension secondary to schistosomiasis, with a good interobserver agreement.

Short esophagus or bad dissected esophagus? An experimental cadaveric study

Short esophagus is defined as the inability to reduce the gastroesophageal junction below the diaphragm. One of the factors responsible for this inability can be inadequate esophageal mobilization. We evaluated esophageal lengthening achieved by means of dissection in a cadaveric model. Fifty-one cadavers were dissected (27 transthoracically and 24 transhiatally). Abdominal esophageal length was assessed before and after dissection of the esophagus from the hiatus to the carina. In the transthoracic group, a mean of 1.7 ± 1.3 cm (range0.3 to 5.0cm) was gained with dissection. In the transhiatal group, a mean of 1.8 ± 0.8 cm (range 0 to 3.0 cm) was gained with dissection. In a comparison of results of transthoracic and transhiatal approaches, the difference was not statistically significant. We concluded that a significant increase in esophageal length was achieved after dissection; however, the access route (thorax or abdomen) did not influence the results.

Anatomical analysis of the mediastinal lymph nodes of normal Brazilian subjects according to the classification of the Japanese Society for Diseases of the Esophagus.

Abstract.Purpose: Extended mediastinal lymphadenectomy is gaining popularity in the treatment of esophageal cancer, but lymph node nomenclature and classification is still not standardized. The normal mediastinal lymph node distribution according to the classification of the Japanese Society for Esophageal Diseases has never been studied. Methods: We dissected 20 fresh adult cadavers to examine the mediastinal lymph nodes. Results: We found an unpredictable and inconstant distribution. Conclusion: Previous papers have evaluated the number and distribution of normal mediastinal lymph nodes, clinically, radiologically, and anatomically, but the results are conflicting and inconsistent.

Primary retroperitoneal mucinous cystadenoma - case report.

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Effects of increased intra-abdominal pressure on the healing process after surgical stapling of the stomach of dogs

PURPOSE To assess the initial healing after surgical stapling of the stomach using a linear cutting stapler and creating pneumoperitoneum (12-14 mmHg) for 60 minutes or 120 minutes, and compare it with the healing of a staple line not submitted to increased pressure. METHODS A total of 30 dogs were divided into three groups of 10 animals each: Group I (control group - surgical stapling), Group II (surgical stapling and increased intra-abdominal pressure for 60 minutes) and Group III (surgical stapling and increased intra-abdominal pressure for 120 minutes). All dogs were maintained under general anesthesia for two hours after surgical stapling. Seven days after surgery, the area around the staple line was macroscopically and microscopically examined. RESULTS The macroscopic examination of the samples (n = 30) did not show dehiscence, fistula or abscess. Adhesions between the omentum and the staple line were observed in all animals of Groups II and III (n = 20), which were significantly different from Group I (p = 0.008*). The histopathological analysis showed normal healing up to day 7 in the control animals (n = 10). When these results were compared with those of Groups II and III (n = 20), non-parametric tests revealed that there was a significant difference with regard to certain parameters of the early stages of healing, such as fibroblast migration (p = 0.011*), edema (p < 0.001*) and congestion (p = 0.011*). These alterations affected reepithelization (p < 0.001*), and consequently the late stages of healing. CONCLUSIONS Each group showed different healing stages, and the healing process was delayed in the groups submitted to increased pressure, especially in the group submitted to increased pressure for longer time.

High-resolution Manometry Findings in Patients After Sclerotherapy for Esophageal Varices.

Background/Aims Endoscopic therapy for esophageal varices may lead to esophageal dysmotility. High-resolution manometry is probably the more adequate tool to measure esophageal motility in these patients. This study aimed to evaluate esophageal motility using high resolution manometry following eradication of esophageal varices by endoscopic sclerotherapy. Methods We studied 21 patients (11 women, age 52 [45–59] years). All patients underwent eradication of esophageal varices with endoscopic sclerotherapy and subsequent high resolution manometry. Results A significant percentage of defective lower esophageal sphincter (basal pressure 14.3 [8.0–20.0] mmHg; 43% hypertonic) and hypocontractility (distal esophageal amplitude 50 [31–64] mmHg; proximal esophageal amplitude 40 [31–61] mmHg; distal contractile integral 617 [403–920] mmHg · sec · cm; 48% ineffective) was noticed. Lower sphincter basal pressure and esophageal amplitude correlated inversely with the number of sessions (P < 0.001). No manometric parameter correlated with symptoms or interval between last endoscopy and manometry. Conclusions Esophageal motility after endoscopic sclerotherapy is characterized by: (1) defective lower sphincter and (2) defective and hypotensive peristalsis. Esophageal dysmotility is associated to an increased number of endoscopic sessions, but manometric parameters do not predict symptoms.