Formaçäo do cirurgiäo em cirurgia laparoscópica do aparelho digestivo. Experiência de 1.818 intervençöes sem acidentes e sem mortalidade / Digestive tract laparoscopic surgeon formations. experience de 1.818 interventions whithout complications or mortality

Desde a instalação da cirurgia laparoscópica no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, a Disciplina de Cirurgia do Aparelho Digestivo passou a estruturar um programa para a formação do cirurgião em laparoscopia do aparelho digestivo. Objetivo. A estrutura de ensino inclui a informação no ensino médico regular, extensão na Liga de Cirurgia Laparoscópica, formando o médico a partir de residência, principalmente em seu quarto ano, com estágio na Unidade de Cirurgia Laparoscópica de três meses. Método. Este modelo de formação e preparo do cirurgião do aparelho digestivo assim implantado, com rigor, profundidade e seriedade é, certamente, responsável pelos resultados de nível excelência obtidos. Resultados. Exemplo disso representam as 1818 colecistectomias laparoscópicas realizadas na Unidade de Cirurgia Laparoscópica no período de outubro de 1990 a dezembro de 1998, com índice de conversão de 0,9 por cento e sem mortalidade. A ausência de acidentes operatórios e de complicações verificadas na experiência adquirida nas operações realizadas por nosso grupo cirúrgico, dá consistente suporte à orientação assumida pela Disciplina. Conclusão. Reforçam-se os princípios que foram adotados dentro da atividade em hospital universitário, que são: necessidade de formação de profissionais dentro de programa bem estruturado, ensejando-lhes preparo educacional humanístico e técnico, em torno de projeto pedagógico longo, mas com grande e sólido embasamento informativo e prático.

Tratamento cirúrgico dos insulinomas: estudo de 59 casos / Surgical treatment of insulinoma: study of 59 cases

Após a confirmaçao clínica e laboratorial de hiperinsulinismo, o principal problema consiste na localizaçao precisa da lesao no parênquima pancreático, propiciando tratamento cirúrgico adequado. Objetivo. Analisar os métodos utilizados para o diagnóstico e localizaçao pré e intra-operatório dos insulinomas, bem como as técnicas e os resultados do tratamento cirúrgico. Métodos. Foram estudados 59 casos consecutivos de insulinoma submetidos a intervençao cirúrgica. Cada um dos métodos utilizados para a localizaçao pré-operatória dessas lesoes foi avaliado quanto à sua eficiência em confronto com os achados intra-operatórios. A palpaçao do pâncreas, isoladamente ou associada à ultra-sonografia intra-operatória, como métodos de localizaçao dos insulinomas, foi também estudada. Os tipos de intervençao cirúrgica foram analisados quanto aos seus resultados imediatos e tardios. Resultados. Dos 59 insulinomas, 55 eram benignos e quatro, malignos. Dos métodos utilizados para a localizaçao pré-operatória, a ultra-sonografia foi eficiente em 28,1 por cento dos casos, a tomografia computadorizada em 25 por cento, a ultra-sonografia endoscópica em 27,2 por cento, a arteriografia seletiva em 54,1 por cento e a colheita de amostras de sangue portal para dosagem de insulina em 94,4 por cento dos casos. A palpaçao bidigital, durante a intervençao cirúrgica, localizou as lesoes em 54/55 casos (98,2 por cento). A ultra-sonografia intra-operatória foi decisiva em apenas um caso. Cinco doentes apresentavam neoplasia endócrina múltipla tipo I e em todos as lesoes pancreáticas eram múltiplas. Foram efetuadas 29 enucleaçoes e 32 ressecçoes pancreáticas nos doentes com lesoes benignas. Os doentes com lesoes malignas foram submetidos a ressecçoes pancreáticas e quimioterapia. Nao houve mortalidade, porém observaram-se complicaçoes (fístulas) em 29/59 casos. Os resultados foram bons em 98,1 por cento dos doentes com lesoes benignas. Apenas um dos doentes com lesoes malignas. sobreviveu cinco anos. Três doentes portadores de lesoes benignas e submetidos a ressecçoes pancreáticas evoluíram com diabetes tardiamente. Conclusoes. A localizaçao pré-operatória nao é absolutamente necessária desde que a palpaçao bidigital associada a ultra-sonografia intra-operatória permite a localizaçao de todas as lesoes. As enucleaçoes devem ser utilizadas, quando possível, de preferência às ressecçoes pancreáticas nas lesoes benignas.

Hepatic damage during acute pancreatitis in the rat

We studied the alterations in the metabolism of liver mitochondria in rats with acute pancreatitis. Male Wistar rats were allocated to a control group (group I) and to five other groups corresponding to 2,4, 12,24 and 48 h after the induction of acute pancreatitis by the injection of 5 per cent sodium taurocholate into the pancreatic duct. Sham-operated animals were submitted to the same surgical steps except for the induction of acute pancreatitis. Mitochondrial oxidation and phosphorylation were measured polarographically by determining oxygen consumption without ADP (basal respiration, state 4) and in the presence of ADP (activated respiration, state 3). Serum amylase, transaminases (ALT and AST) and protein were also determined. Ascitic fluid, contents of amylase, trypsin and total protein were also determined and arterial blood pressure was measured in all groups. In ascitic fluid, trypsin and amylase increased reaching a maximum at 2 and 4h, respectively. Serum amylase increased at 2 h reaching a maximum at 4 h. Serum transaminase levels increased at 12 and 24 h. After 2 h (and also 4 h) there was an increase in state 4 respiration (45.65 + 1.79 vs 28.96 + 1.50) and a decrease in respiration control rate (3.53 + 0.09 vs 4.45 + 0.08) and in the ADP/O ratio (1.77 + 0.02 vs 1.91 + 0.01) compared to controls (P<0.05). These results indicate a disruption of mitochondrial function, which recovered after 12 h. In the 48-h groups there was mitochondrial damage similar to that occurring in ischemic lesion. Beat-to-beat analysis (30 min) showed that arterial blood pressure remained normal up to 24 h (111 + 3 mmHg) while a significant decrease occurred in the 48-h group (91 + 4 mmHg). These data suggest biphasic damage in mitochondrial function in acute pancreatitis: an inital uncoupled phase, possibly secondary to enzyme activity, followed by a temporary recovery and then a late and final dysfunction, associated with arterial hypotension, possibly related to ischemic damage.

Reduction of pancreatic enzyme content and mortality in experimental acute pancreatitis in rats

A previous report has shwon that undernutrition reduces the mortality of acute experimental pancreatitis probably by decreasing pancreatic enzyme content of the pancreas without any harmful effect on the organ. The aim of the present study was to assess the effect of acute reduction of pancreatic enzyme content on the outcome of acute pancreatitis. Two groups of males Wistar rats weighing 230-250 g were studied: group I, 12-h fasted animals, and group II, add libitum-fed animals who received cerulein at the inframaximal dose (0.2 µg kg-1h-1) for 2 h. Cerulein adminsitration resulted in the reduction of the pancreatic contents of chymotrypsinogen (71 percent), trypsinogen (55 percent), proelastase (60 percent), amylase (62 percent) and cathepsin B (45 percent) (P<0.05). However, no significant reduction in pancreatic phospholipase content was observed. Acute pancreatitis wass induced in group I after 12-h fasting and in group II at the end of cerulein infusion by retrograde injection of 0.5 ml of 2.5 percent Na+ taurocholate into the pancreatic duct. Ascites volume and the degree of histologically observed lesions were similar in both groups, but 72-h mortality was 56 percent in the control group (10/18) and 23 percent (5/22) in the cerulein group (P<0.05). We speculate that the reduction of pancreatic enzyme content may exert its beneficial effect in acute pancreatitis by decreasing the quantity of pancreatic enzymes reaching the circulation and consequently their pathogenic effects

Mononuclear phagocytic system in acute pancreatitis

1. Functional alterations of the mononuclear phagocytic system (MPS) may be an important factor in the pathogenesis of infection in acute pancreatitis (AP). In the present study, MPS activity was investigated in rats and hepatic blood flow (HBF) was also determined. 2. A total of 122 male Wistar rats were divided into three groups: 1, AP group (N = 51); 2, sham-operated (SO) (N = 49); 3, intact group (IG) (N = 22). AP was induced by retrograde injection of 0.5 ml of 2.5 per cent sodium taurocholate saline into the main biliopancreatic duct under ketamine chloride anesthesia. SO animals were submitted to the same surgical steps as AP animals except for AP induction. 3. Each experimental group was subdivided into two subgroups. The first subgroup was submitted to the study of MPS activity as follows: each group was injected with colloidal 198Au and liver clearance parameters were determined 2 h (N = 11), 12 h (N = 10) and 24 h (N = 10) later in the AP group, and 2 h (N = 9), 12 h (N = 10) and 24 h (N = 11) later in the SO group. In the second subgroup, HBF was assessed using 131I-bromosulphalein at 2 h (N = 10) and 24 h (N = 10) in the AP group and at 2 h (N = 10) and 24 h (N = 10) in the SO group. The IG was submitted to both radioactive tracer studies. Each animal was used for only one experiment.(ABSTRACT TRUNCATED AT 250 WORDS)

Modifications of tissue blood flow in acute pancreatitis

I.Acute pancreatitis (AP) was induced by ductal injection of 2.5% sodium taurocholate saline solution. Plasma and red blood cell (RBC) volume and visceral organ blood flow were evaluated by a radioisotopic method (51Cr tracers) in 45 adult male Wistar rats (22 submitted to AP and 23 controls) 4 h after AP induction. 51Cr-albumin was used to measure plasma volume and 51Cr-RBC was used to measure RBC volume. II.Changes in tissue hematocrit reflect alterations in tissue blood flow, since reduction in blood flow increases microvascular erythrocyte sequestration. To evaluate the tissue blood flow, we introduce a "tissuehematocrit index" calculated relating 51Cr-RBC and 51Cr-albumin specific activities measured in visceral organ biopsies. Application of this index to the control and AP groups showed a decrease in blood flow in all visceral organs of the AP group which was reflected by an increase in tissue hematocrit index (2.5-fold for kidneys, 2-fold for pancreas and lungs, 1.6-fold for liver, and 1.2-fold for spleen). III.As expected there was an increase in blood hematocrit and a decrease in plasma volume in the AP group, but there were no significant alterations in RBC volume. However, an unequal decrease in blood flow in various tissues such as kidneys, lungs, pancreas and liver was detected in the AP group. IV.This approach provides an easy and simple way to evaluate possible therapeutic protocols for the treatment of acute panreatitis by measuring effects on visceral blood flow and plasma and blood volumes