Tarcísio Triviño

Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors

The progression of certain primary esophageal motor disorders to achalasia has been documented; however, the true incidence of this decay is still elusive. This study aims to evaluate: (i) the incidence of the progression of diffuse esophageal spasm to achalasia, and (ii) predictive factors to this progression. Thirty-five patients (mean age 53 years, 80% females) with a manometric picture of diffuse esophageal spasm were followed for at least 1 year. Patients with gastroesophageal reflux disease confirmed by pH monitoring or systemic diseases that may affect esophageal motility were excluded. Esophageal manometry was repeated in all patients. Five (14%) of the patients progressed to achalasia at a mean follow-up of 2.1 (range 1-4) years. Demographic characteristics were not predictive of transition to achalasia, while dysphagia (P= 0.005) as the main symptom and the wave amplitude of simultaneous waves less than 50 mmHg (P= 0.003) were statistically significant. In conclusion, the transition of diffuse esophageal spasm to achalasia is not frequent at a 2-year follow-up. Dysphagia and simultaneous waves with low amplitude are predictive factors for this degeneration.

SOLID PSEUDOPAPILLARY NEOPLASM OF THE PANCREAS

ABSTRACT Background: The solid pseudopapillary neoplasm is a rare tumor of the pancreas. However, it´s etiology still maintain discussions. Aim: To analyze it´s clinical data, diagnosis and treatment. Methods: A retrospective study of medical records of all patients treated from January 1997 until July 2015. Results: Were identified 17 cases. Most patients were women (94.11%) and the average age was 32.88 years. The main complaint was abdominal mass (47.05%). The most frequent location was in the body/tail of the pancreas (72.22%) and the most frequently performed surgery was distal pancreatectomy with splenectomy (64.70%). No patient had metastases at diagnosis. Conservative surgery for pancreatic parenchyma was performed in only three cases. The rate of complications in the postoperative period was 35.29% and the main complication was pancreatic fistula (29.41%). No patient underwent adjuvant treatment. Conclusions: The treatment is surgical and the most common clinical presentation is abdominal mass. Distal pancreatectomy with splenectomy was the most frequently performed surgery for its treatment.

Insulinoma de páncreas

Resumen El insulinoma es la neoplasia mas frecuente del grupo de tumores neuroendocrinos de pancreas. En el presente estudio se evaluaron los resultados clinicos e inmunohistoquimicos de 20 casos de pacientes tratados quirurgicamente desde enero de 1986 hasta diciembre de 2004. Se describio el cuadro clinico, los examenes de laboratorio e imageneologicos, y se hizo enfasis en los aspectos quirurgicos, las complicaciones y el seguimiento a medio y largo plazo. La cirugia se indico sobre la base de las evidencias clinicas y analiticas de hipoglucemia e hiperinsulinemia. En 15 pacientes se logro la localizacion previa de la lesion, en 5, su localizacion fue identificada durante la cirugia mediante la palpacion y a traves del ultrasonido intraoperatorio. Los procedimientos quirurgicos realizados con mas frecuencia fueron la reseccion pancreatica en la mitad de los pacientes y la enucleacion por laparotomia en la otra mitad. En 2 pacientes se utilizo la via laparoscopica. Dos presentaron tardiamente diabetes mellitus. La complicacion quirurgica mas frecuente fue la fistula pancreatica en 13 de los casos. No hubo mortalidad en la presente serie. En la totalidad de los pacientes se obtuvo la reversion clinica de los sintomas, caracterizada por la desaparicion de la triada de Whipple, ademas de la normalizacion o el aumento de los valores de glucemia, comparados con los valores del preoperatorio.

Carcinoma of the Papilla of Vater: Are Endoscopic Appearance and Endoscopic Biopsy Discordant?

Carcinoma of the papilla of Vater is classified as periampullary cancer representing 5% of all gastrointestinal tract malignancies. Early and accurate diagnosis is important for those patients with a tumor of the papilla, as the prognosis is more favorable than in other periampullary neoplasms. Endoscopically obtained biopsies from suspicious papillae can detect an early tumor, although even for skilled pathologists it is often difficult to differentiate carcinomas from noninvasive lesions on the basis of forceps biopsies. The purpose of this study was to assess the preoperative diagnostic accuracy of duodenoscopy appearance and biopsy in all cases with suspicion of tumor. Thirty patients with suspicion of carcinoma of the papilla of Vater and with final diagnosis established by pancreatoduodenectomy were included in this retrospective study. In each case, a comparison was made between endoscopic biopsy and duodenoscopic appearance. Duodenoscopic appearance sensitivity and accuracy for malignancy were 86% and 83%, respectively, whereas endoscopic biopsy sensitivity and accuracy were 65% and 67%, respectively. Although preoperative diagnosis of carcinoma of the papilla of Vater is useful for making therapeutic decisions, the diagnostic value of the endoscopic appearance was superior to endoscopic biopsy in this series.

Insulinomas do pâncreas: diagnóstico e tratamento

BACKGROUND Despite its rarity, the insulinoma is the most common pancreatic neuroendocrine tumor. OBJECTIVE Analyze clinical and immunohistochemical data from surgical resection of the pancreas insulinoma. METHOD Twelve cases are described, concerning surgical aspects, complications and medium-long term outcome of patients. They underwent surgical treatment due to clinical suspicion and biochemical diagnosis of hypoglycemia and hyperinsulinism. RESULTS The insulinoma was identified preoperatively in seven patients, while intraoperative ultrasonography and palpation were necessary for diagnosis in the other cases. Eight patients underwent pancreatic resection and pancreatic leak was observed in seven cases. Two patients developed diabetes mellitus and no mortality occurred in the current series. CONCLUSION All patients presented satisfactory outcome and remained asymptomatic with normal glicemia levels.

Anatomia cirúrgica do fígado

PURPOSE: The aim of this article is to sudy the functional anatomy of the liver and its segmentation, based on vascular (venous) structures in the parenquima. METHODS: Liver dissection in recent cadavers, identifying the portal pedicles and hepatic veins, which define the liver segments or its functional units. RESULTS: Anatomic caracterization of the eight liver segments, its afferent and efferent vascular structures, in order to guide anatomical resections that preserve the function and irrigation of the remaining segments. CONCLUSION: The knowledge of functional anatomy of the liver, based on its segmentation, is the basis of the modern hepatic surgery.

Laparoscopic cholecystectomy in a patient with a duplicated cystic duct.

Cystic duct duplication with a single gallbladder is one of the most uncommon abnormalities of the biliary tract, with fewer than 15 instances published. The authors describe a 49-year-old patient undergoing a laparoscopic cholecystectomy in whom a second cystic duct was found, initially misdiagnosed as the biliary tract. The cholecystectomy was performed successfully with the aid of intraoperative cholangiography. It is the first time a duplicated cystic duct has been treated successfully using a laparoscopic approach.

Opções técnicas utilizadas no transplante pancreático em centros brasileiros

OBJETIVO: Analisar o perfil dos principais centros de transplantes do Brasil, quanto as opcoes tecnicas no transplante de pâncreas. METODO: Foi encaminhado um questionario por correio eletronico (email) para um membro de cada equipe de 12 centros de transplante do Brasil, com casuistica minima de um transplante de pâncreas. O questionario continha 10 perguntas, abordando aspectos controversos e nao padronizados. RESULTADOS: A maioria dos centros (90,9%) utiliza incisao mediana. O orgao de escolha a ser implantado primeiro foi principalmente o rim, em 63% dos centros. Em relacao a drenagem venosa, 90,9% utilizam a drenagem sistemica. A ligadura da veia iliaca interna e realizada em 54,5% dos centros. A maioria dos centros (90,9%) utiliza a drenagem enterica para transplante combinado pâncreas-rim. Para o transplante de pâncreas isolado, apenas cinco centros responderam, sendo que dois utilizam a drenagem enterica e tres a vesical. A utilizacao de dreno na cavidade abdominal ocorre em 63% dos centros. Em 72,7% dos centros e realizada algum tipo de inducao na imunossupressao para o transplante combinado pâncreas-rim, sendo a imunossupressao basica a associacao de tacrolimus (FK506), micofenolato mofetil (MMF) e corticoide. A antibioticoprofilaxia e realizada por todos os centros e profilaxia para fungos e realizada por seis centros (54,5%). Oito centros (72,7%) utilizam algum tipo de profilaxia para trombose vascular, em esquemas diversos. CONCLUSAO: Existem diversos caminhos tecnicos na conducao do transplante pancreatico. A falta de padronizacao dificulta a analise e a comparacao dos resultados. Apesar dessa heterogeneidade das equipes, observamos uma tendencia para a realizacao de incisao mediana, drenagem venosa sistemica e exocrina enterica, com a utilizacao de algum tipo de profilaxia para trombose vascular nos transplantes combinados pâncreas-rim.

Extra-pancreatic vipoma

Neuroendocrine tumors of the pancreas are rare neoplasms representing approximately 2% of all pancreatic tumors9. Due to the progress of diagnostic imaging and radioimmunoassay, its diagnosis has become more frequent. Recent epidemiological studies suggest increased frequency12. Among the functioning tumors, vipoma (tumor cells producing vasoactive intestinal polypeptide) is also known as WDHA syndrome (watery diarrhea, hypokalaemia, and achlorhydria), Werner Morrison ́s syndrome and pancreatic cholera; it is still rare neoplasia, mainly characterized by profuse diarrhea with hydroelectrolytic disorders. It has an estimated incidence of 0,2 to 0,5 per million inhabitants per year3. Approximately 90% of these tumors originate in the pancreas; however, there are descriptions located in other segments of the gastrointestinal tract, bronchus, adrenal, sympathetic ganglia and liver. There are few cases described in the medical literature of extrapancreatic location in adults8. Due to its low incidence, it is unknown the true epidemiological data of this unique neoplasm. The objective of this report is to present another case of extra-pancreatic vipoma.

Tumor neuroendocrino quístico no funcionante del páncreas. Una presentación poco usual

Pancreatic endocrine neoplasms are a group of tumors that sporadically affect this gland, although their etiopathogenesis, diagnosis and treatment are still object of debate. The approximate incidence of these neoplasms is from 1 to 2% of all pancreatic tumors and their clinical symptoms depend on the production of hormones or biologically active amines. The cystic presentation of these tumors is a much rarer situation (approximately 4.5%), which usually makes their preoperative diagnosis difficult. Therefore, they are frequently confused with other cystic neoplasms of the pancreas with different therapeutic approaches, such as serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and epithelial cysts, among others. The aim of this letter is to present 3 new cases of nonfunctioning pancreatic neuroendocrine tumors with predominantly cystic characteristics. The patients are two females, aged 53 and 63, and one male, aged 25. The first two patients presented no specific symptoms. The male patient was in follow-up for a diagnosis of multiple endocrine neoplasia type 1 (MEN-1) and Cushing’s disease. The diagnosis of the pancreatic lesions was incidental. Computed tomography showed evidence of a cystic formation with hypodense areas measuring 3.5 cm in the body of the pancreas in the first case (Fig. 1A). In the second case, a solid cystic lesion was detected in the uncinate process measuring 1.7 cm (Fig. 2A), which was confirmed by endoscopic ultrasound. And, in the third case, magnetic resonance showed a predominantly cystic lesion with cell thickening in the tail of the pancreas measuring 6.2 cm. Surgery was indicated in all cases: in the first, pancreatectomy of the body and tail of the pancreas with splenectomy (Fig. 1B); in the second, pylorus-preserving pancreaticoduodenectomy (Fig. 2B); and, laparoscopic distal splenopancreatectomy in the third case. This last patient presented a type Ipancreatic fistula in the postoperative period. Hematoxylin-eosin confirmed the diagnosis of well-differentiated pancreatic endocrine neoplasm, with mitotic index inferior to 10 fields in the 3 cases. Immunohistochemistry showed positivity for chromogranin A, cytoplasmic neuroendocrine marker and neuron-specific enolase in the first case. The second case was positive for chromogranin A, synaptophysin, progesterone receptor 1A6, Mib-1, AE1, AE3 and the proliferation rate (Ki-67) was 5%. In the third patient, this method was positive for somatostatin, enolase monoclonal, chromogranin A, synaptophysin and glucagon, with Ki-67 less than 1%. The first 2 patients had no symptoms in follow-up, and the third patient continues in clinical and endocrinological follow-up. The development of diagnostic imaging methods in recent decades has undoubtedly resulted in the diagnosis of a series of asymptomatic pancreatic neoplasms, which before would probably have gone undetected with traditional methods. This has also led to controversial situations in the diagnosis and especially the treatment of certain diseases. Among these incidental diagnoses, pancreatic endocrine neoplasms are the most frequent. Their low incidence causes great diagnostic difficulties due to the absence of characteristic disease symptoms. This diagnostic difficulty can increase when these endocrine tumors adopt a cystic form,