Small cell carcinoma of the esophagus / Carcinoma de pequenas células do esôfago

BACKGROUND: Small cell carcinoma of the esophagus is a rare disease, characterized by aggressive progression, which is similar in appearance and behavior to its counterpart of the lung. It has a high incidence of metastatic disease at presentation and a poor prognosis. Treatment protocols are not well established because of the small number of cases and lack of large studies. CASE REPORT: 66 year-old woman, was admitted to the hospital with persistent dysphagia. Radiologic and endoscopic examination revealed an stenosing tumor in the lower third of the esophagus. The biopsy specimen was diagnosed as small cell carcinoma of the esophagus. The patient underwent an esophagectomy with esophagogastric anastomosis. CONCLUSION: The role of surgery remains controversial and the improvement of life quality is to be considered. Therapeutic approach is mainly esophageal resection.

RACIONAL: O carcinoma de pequenas células do esôfago é rara afecção, caracterizada por uma progressão agressiva, sendo seu aspecto e comportamento semelhantes aquele do pulmão. Detém elevada incidência de doença metastática em sua apresentação inicial, dado que lhe empresta prognóstico reservado na maioria dos casos. Protocolos de tratamento não são bem definidos, devido ao pequeno número de casos relatados na literatura. RELATO DE CASO: Apresenta-se caso de mulher de 66 anos admitida no hospital com queixa de disfagia. Avaliação radiológica e endoscópica revelaram lesão estenosante no terço inferior do esôfago, cuja biópsia mostrou tratar-se de carcinoma de pequenas células do esôfago. A paciente foi submetida à esofagectomia e reconstrução com tubo gástrico. CONCLUSÃO: O papel da cirurgia permance controverso e a melhora na qualidade de vida deve ser considerada. O tratamento terapêutico principal continua sendo a resecção esofágica.

Duodenal angiodysplasia: case report and literature review / Angiodisplasia duodenal: relato de caso e revisão da literatura

BACKGROUND: Angiodysplasia is a distinct mucosal vascular lesion associated with acute or chronic gastrointestinal bleeding. It occurs most frequently in the right colon and is extremely rare. Its etiology is unknown, but theories of its pathogenesis have evolved from its similarity to colonic angiodysplasia and the lesion appears to be associated with renal insufficiency. CASE REPORT: Sixty-five-year-old woman with repeated melena and severe anemia due to angiodysplasia in the first portion of the duodenum. The diagnosis was done by upper endoscopy. As the patient presented repeated gastrointestinal bleeding with hemodynamic instability and recurrent anemia, surgery was indicated. At laparotomy the lesion was identified and resected with an Y-en-Roux reconstruction. The patient went on well at the immediate and late (four years) postoperative periods with no more recurrent gastrointestinal bleeding. CONCLUSION: Although most of the patients suffering from gastrointestinal angiodysplasia goes on well with conservative management, there is a small portion of them that will need a more aggressive approach, as in this case.

RACIONAL: Angiodisplasia duodenal é uma lesão vascular distinta da mucosa intestinal associada com sangramento agudo ou crônico. Embora seja extremamente rara no duodeno, ocorre com maior freqüência no cólon direito. Tem etiologia desconhecida, mas sua patogênese parece semelhante com a do cólon. Em alguns casos está associada à insuficiência renal. RELATO DO CASO: Paciente de 65 anos de idade com episódios repetidos de melena e anemia severa devido à presença de lesão angiodisplásica na primeira porção do duodeno, cujo diagnóstico fôra estabelecido por endoscopia digestiva alta. Como ela apresentara-se com episódios repetidos de hemorragia digestiva alta acompanhados de instabilidade hemodinâmica, foi-lhe indicada cirurgia. À laparotomia, identificou-se a lesão, que foi ressecada, sendo realizada reconstrução em Y-de-Roux. Evoluiu bem no período pós-operatório imediato e encontra-se sem novos episódios de sangramento 4 anos após a cirurgia. CONCLUSÃO: Embora a maioria dos pacientes com angiodisplasia gastrintestinal evolua satisfatoriamente com manejo conservador, existe pequena fração que necessitará de abordagem mais agressiva. Neste caso, a paciente apresentou claro benefício da conduta cirúrgica proposta, visto que não apresentou mais episódios de hemorragia digestiva alta.

Retirada de fasciola hepatica da via biliar principal por coledocoscopia / Fasciola hepatica removal from common duct through choledocoscopy

The authors present a rare case of hepatic fascioliasis in a female patient 53-years-old, coming from the rural zone of Rio Grande do Sul, a southern State from Brazil. She has presented with biliary colic, fluctuant jaundice and eosinophilia. Abdominal ultrasound has shown a dilated biliary tree with inside heterogeneous images. At surgery we have found inside the biliary tree several Fasciola hepatica, which have been pulled out with the choledocoscope. We have proceeded with biliodigestive anastomosis using the small intestine. The patient remains asymptomatic six months after surgical procedure. Small intestine. The patient remains asymptomatic six months after surgical procedure.

Comparaçäo do efeito de dois inibidores da HMG CoA redutase sobre a suscetibilidade da LDL à oxidaçäo / Comparison of the effect of two HMG CoA reductase inhibitors on LDL susceptibility to oxidation

OBJECTIVE: To study the differences between fluvastatin and pravastatin regarding LDL susceptibility to oxidation, plasma levels of total cholesterol (TC), HDL-C, LDL-C and triglycerides (TG) in hypercholesterolemic patients with established coronary heart disease (CHD). METHODS: A double-blind randomized parallel study was conducted that included 41 hypercholesterolemic outpatients with CHD treated at the Instituto de Cardiologia do Rio Grande do Sul. The inclusion criteria were LDL-C above 100 mg/dL and triglycerides below 400 mg/dL based on 2 measures. After 4 weeks on a low cholesterol diet, those patients that fullfilled the inclusion criteria were randomized into 2 groups: the fluvastatin group (fluvastatin 40 mg/day) and the pravastatin group (pravastatin 20 mg/day), for 24 weeks of treatment. LDL susceptibility to oxidation was analyzed with copper-induced production of conjugated dienes (Cu2+) and water-soluble free radical initiator azo-bis (2'-2'amidinopropanil) HCl (AAPH). Spectroscopy nuclear magnetic resonance was used for determination of lipids. RESULTS: After 24 weeks of drug therapy, fluvastatin and pravastatin significantly reduced LDL susceptibility to oxidation as demonstrated by the reduced rate of oxidation (azo and Cu) and by prolonged azo-induced lag time (azo lag). The TC, LDL-C, and TG reduced significantly and HDL-C increased significantly. No differences between the drugs were observed. CONCLUSION: In hypercholesterolemic patients with CHD, both fluvastatin and pravastatin reduced LDL susceptibility to oxidation

Modelo experimental de transfecção gênica em miocárdio normal de cães: perspectivas de terapia gênica para o tratamento da cardiopatia isquêmica / Experimental model of gene transfection in healthy canine myocardium: perspectives of gene therapy for ischemic heart disease

OBJECTIVE: To assess the transfection of the gene that encodes green fluorescent protein (GFP) through direct intramyocardial injection. METHODS: The pREGFP plasmid vector was used. The EGFP gene was inserted downstream from the constitutive promoter of the Rous sarcoma virus. Five male dogs were used (mean weight 13.5 kg), in which 0.5 mL of saline solution (n=1) or 0.5 mL of plasmid solution containing 0.5 æg of pREGFP/dog (n=4) were injected into the myocardium of the left ventricular lateral wall. The dogs were euthanized 1 week later, and cardiac biopsies were obtained. RESULTS: Fluorescence microscopy showed differences between the cells transfected and not transfected with pREGFP plasmid. Mild fluorescence was observed in the cardiac fibers that received saline solution; however, the myocardial cells transfected with pREGFP had overt EGFP expression. CONCLUSION: Transfection with the EGFP gene in healthy canine myocardium was effective. The reproduction of this efficacy using vascular endothelial growth factor (VEGF) instead of EGFP aims at developing gene therapy for ischemic heart disease

Desfechos clínicos tardios da cirurgia de Fontan em pacientes com atresia tricúspide / Late clinical outcomes of the Fontan operation in patients with tricuspid atresia

OBJECTIVE: Evaluation of the long-term clinical results of the Fontan operation in patients with tricuspid atresia. METHODS: A retrospective analysis was made at the Instituto de Cardiologia do Rio Grande do Sul (Institute of Cardiology of Rio Grande do Sul), from August 1980 through January 2000, of 25 patients with a long-term follow-up, out of a series of 36 patients who underwent the Fontan operation or one of its variants due to tricuspid atresia. Their mean age at surgery was 5.4±3.1 years, and their mean weight was 15.8±6.1 kg, the majority of them (63.9 percent) being males. Four patients underwent the classical Fontan operation, 12 the Kreutzer variant, 6 the Björk variant, 9 total cavopulmonary shunt with a fenestrated tube, and 5 total cavopulmonary shunt with a nonfenestrated tube. RESULTS: The patients were followed-up on an outpatient basis, with a mean long-term survival time of 5.5±4.2 years (50 days to 17.8 years) and a late mortality rate of 8 percent. Arterial saturation increased from 77.2±18.8 percent in the preoperative period to 91±6.7 percent upon the last outpatient visit (p>0.05). At the final check, most (67 percent) patients were asymptomatic and 87 percent could tolerate exercise. Ten (40 percent) patients experienced some kind of complication during the long-term follow-up, such as cardiac arrhythmia, cyanosis, protein-losing enteropathy, neurological events, right heart failure, intolerance to exercise and reoperation. CONCLUSION: The results indicate that, once the immediate postoperative period is over, during which the adaptations to the new circulatory physiology occur, the evolution of patients with tricuspid atresia who underwent the Fontan operation is satisfactory, in spite of a low, yet significant, morbidity

Cateteres venosos totalmente implantáveis em pacientes com neoplasia hematológica e não hematológica / Totally implantable venous catheters in patients with hematological and non hematological neoplasias

OBJETIVO: Analisar se a presença de neoplasia hematológica acarreta maior risco de complicações para inserção de cateteres totalmente implantáveis e se há diferença de tempo cirúrgico quando o procedimento é realizado por punção ou dissecção venosa. MÉTODO: Foram avaliados 68 pacientes com neoplasia internados no Hospital Santa Rita de Porto Alegre entre fevereiro de 1998 e dezembro de 1999, os quais necessitavam de acesso venoso central para tratamento quimioterápico, sendo 48 do sexo feminino e com idade média de 55,6 anos. Desses, 31 apresentavam neoplasia hematológica. RESULTADOS: Complicações pós-operatórias ocorreram em 13 pacientes (19 por cento), sendo elas: obstrução do sistema (7 por cento), hematoma (6 por cento) e infecção (6 por cento), não havendo diferença quanto ao tipo de neoplasia (p = 0,56). Foram realizadas dissecção e punção venosa em 30 e 38 pacientes, respectivamente, sem diferença em relação ao tempo de implantação do cateter (p = 0,42). CONCLUSÃO: Neoplasias hematológicas não aumentaram o risco de complicações quando do uso de cateteres totalmente implantáveis no presente estudo, além disso, ambas as técnicas cirúrgicas - dissecção ou punção - são exeqüíveis, haja visto o tempo cirúrgico semelhante entre elas, desde que sejam respeitados o valor sérico mínimo de plaquetas (50.000/mL) e a técnica cirúrgica apropriada, com hemostasia rigorosa e curativo compressivo.

BACKGROUND: We analyse whether hematological tumors increase the risk of complications of totally implantable catheters and if there are differences regarding procedure time when it is perfomed through venous dissection or venous puncture. METHODS: We studied 68 patients with neoplasia in Hospital Santa Rita from Porto Alegre, between February 1998 and December 1999, who had required central venous access for chemotherapy. Forty-eight patients were female and the mean age was 55.6 years. Thirty-one patients had hematological tumors. RESULTS: Postoperative complications were observed in 13 patients (7 percent with device obstruction, 6 percent with hematoma and 6 percent with infection), but there was no difference regarding the pattern of the neoplasia (p = 0.56). Venous dissection and venous puncture were performed in 30 and 38 patients, respectively, with no difference concerning surgical time (p = 0.42). CONCLUSIONS: Hematological tumors did not increase the risk of complications of totally implantable catheters; furthermore, both surgical techniques (venous dissection or venous puncture) are acceptable choices, with similar surgical times, since one respects minimal platelet count of 50 000/mL and careful hemostasis techniques and compressive dressings.

Ssssobrevida hospitalar dos pacientes cirroticos com bacterioascite / Hospital survival of cirrhotic patients with bacterial ascites

No presente estudo os autores avaliam retrospectivamente a sobrevida hospitalar dos pacientes cirroticos com bacterioascite (BA), sem a utilizacao de antibioticoterapia, comparando-a com a de pacientes com ascite esteril(AE). Para tanto analisaram-se 20 pacientes com BA e 55 com AE, com comprometimento semelhante da funcao hepatocelular. O numero medio de polimorfonucleares no liquido de ascite nos grupos com Ba e Ae foi respectivamente, de 127.88 ñ 58.65 e 104.34 ñ 69.3 (p>0,05). A E. coli foi a bacteria mais prevalente nos pacientes com BA. Sendo a sobrevida dos pacientes semelhante (80por cento nos comBA e 92,7por cento nos com AE), nao esta indicada a utilizacao rotineira de antibioticos nesta populacao de pacientes