Descoberta simultânea de carcinomatose disseminada e carcinoma de cólon, após colecistectomia laparoscópica / Unsuspected colon adenocarcinoma revealed after laparoscopic cholecystectomy

A particularly rapid and fatal outcome has been noted in cases of malignant soft-tissue metastases occurring after cancer surgery. Abdominal wall metastases occurring in scars after laparotomy for cancer resection show a similar poor outcome. On the other hand, neoplasm seeding at trocar sites after laparoscopy has been reported with an increasing frequency. A case is presented of a 68-years-old woman with metastatic seeding of non-diagnosed colon cancer at the umbilical trocar site used for a laparoscopic cholecystectomy. The gallbladder was extracted through the umbilical incision. Pathological examination confirmed chronic cholecystitis. Eight months latter, the patient was seen with a tender umbilical mass protruded through a 4,5 cm the umbilical incision site. Biopsies of this tissue were taken and histopathological examination showed metastatic adenocarcinoma, probably of a gastrointestinal origin. A colonoscopy performed at the same time revealed a 2-cm lesion at the hepatic flexur which was shown to be a differentiated adenocarcinoma. An 8.0 x 6.0 x 6.0-cm pelvic mass without signs of liver metastases was identified by computerised tomography. Diagnostic laparoscopy showed a diffuse peritoneal carcinomatosis. The pelvis could not be approached, except for simple biopsy, and no surgical procedure was performed. It is presumed that the primary colon cancer existed prior to cholecystectomy. Laparoscopy is the procedure of choice to perform cholecystectomy and fundoplication. It has also been increasingly used to diagnose, resect and perform the staging of malignant tumours. As in any relatively new technique, questions arising about its safety and risk of complications must be extensively studied. Many questions about the specific features of laparoscopy promoting cancer growth remain unanswered.

Ressecção videolaparoscópica de hemangiopericitoma do estômago / Laparoscopic resection for hemangiopericytoma of the stomach

In the present case (77 years-old woman), the diagnosis on an extramucosal lesion by endosonography was leiomyoma or schwanoma. Radiological exam of the upper digestive tract with barium and abdominal computed tomography confirmed the site of the lesion at the level of the lesser curvature. The operative technique followed the steps of the laparoscopic partial gastric resection (wedge resection) for gastric mesenchymal tumours, described elsewhere. The Endo-GIA stapler was introduced through the 12mm port in the right upper quadrant. proper positioning of the stapler over the lesser curvature and a satisfactory margin of tissue around the mass were attained. Nine sequential firings of the Endo-GIA 30 were needed to completely surround the mass. Histopathological diagnosis was a spindlecell tumour measuring 3cm in diameter. Mitotic index was measured at almost null. The neoplastic cells were strongly reactive for vimentine and CD34 and negative for the immunohistochemical markers S-100 protein, muscle actin, desmin and Ag linked to VIII factor. There was a slight reaction with keratin (+/+++). The XIIIA factor reaction revealed less than 5 por cento of dendritic elements. These data favour a vascular cell origin better than smooth muscle cell origin. In conclusion it was a gastric hemangiopericytoma. Follow-up showed no recurrence at seven years

Ressecção videolaparoscópica de tumor gástrico estromal situado na parede posterior / Laparoscopic resection of gastric stromal tumour located in the posterior wall

This article suggests a procedure for the removal of gastric stromal tumours by way of video-laparoscopic access, based on a case of undetermined stromal tumour and a review of the literature. In the present case (75 years-old woman), the diagnosis of an extramucous lesion at the level of the greater curvature was achieved by endosonography. Removal of the gastric wall segment including the lesion (coupled with at least two centimetres of the adjacent gastric wall) was performed through successive placement of an automatic suture (Endogia) in the stomach around the implantation base of the tumour. intraoperative gastroscopy has proved to be mandatory, to identify the tumour implantation base and to verify the condition of the mucous surface in suture line. Endoscopic-intragastric tumour exeresis should not be performed because it demands enucleation, which is an inadequate technique for resection of extramucous gastric tumours. In posterior-wall neoplasms, the lesser and greater gastric curvature must be partially freed and from the lesser sac, the lesion can be tackled through the gastric wall. This must be preferred through the laparoscopic-transgastric approach. Endoscopic-intragastric tumour exeresis should not be performed because it demands enucleation, which is an inadequate technique

Leiomiomas do esôfago removidos por vídeo-toracoscopia / Videothoracoscopic resection of esophageal leiomyomas

This report describes three cases of esophageal leiomyomas successfully resected by thoracoscopy. Surgical enucleation through minimally invasive surgery is the treatment of choice for esophageal leiomyoma. The conventional approach through a formal thoracotomy has the potential of causing excessive pain and patient discomfort. Moreover, the hospital stay and the recovery period are prolonged. Indications for surgery were based mainly on the size of the mass (< 4cm) and the presence of dysphagia. In one case there was a clear suspicion of malignancy. The tumour was located in the lower thoracic esophagus (case 1), in the middle thoracic esophagus (case 2) and in the upper esophagus (case 3). The CT was useful in identifying the relationship between the lesion and the organs of the mediastinum. The barium swallow study was able to locate the lesion along the esophagus. The endosonography determined the boundaries of the lesions. A right thoracoscopic approach was undertaken. Dissection of the esophagus around its entire perimeter was never necessary because all tumours were anterior or right sided. The tumours were better grasped with a traction suture than with forceps. The hidrodissection was very helpful. The water-soluble contrast swallow, performed on the fourth postoperative day, was normal. Clinical results were satisfactory in all patients. Biopsies should never be performed when the mucosa overlying is normal

Leiomioma do esôfago removido por videolaparoscopia / Leiomyoma of the lower esophagus treated by videolaparoscopy

This report describes a leiomyoma of the inferior third section of the esophagus removed during laparoscopic cholecystectomy. The patient is a woman 55-years-age, carrying esophageal myoma of 40 mm in diameter wide, situated in the posterior wall of the lower esophagus. Indications for surgery were based mainly on the growth of the mass (6 mm when discovered 7 years previously, increased to 40 mm). Recently the patient returned suffering from pain, which could be attributed to his litiasic cholecystopaty. A small degree of low disphagia could also be observed. Radiologic imaging, direct endoscopic examination and endoscopic ultrasound showed that the mioma protruded on to the oesophagic lumen, discreetly diminishing there. A laparoscopic esophageal myomectomy was indicated at the same session of the laparoscopic cholecystectomy. Once the pneumoperitoneum was installed, five ports were placed as if for a hiatus hernia surgery. The cholecystectomy was uneventful. Next, an esophagoscopy was performed so as to determine the precise area covering the base of the tumour, at the right-lateral site. Longitudinal and circular fibres of the esophagus was severed over the lesion and the enucleation of the tumour was performed alternating the monopolar dissection, bipolar and hidrodisection. Control-endoscopy was carried out to verify mucosa integrity. Four suture points with poliglactine 3-0 string so as to close the musculature followed this. One suture was placed in for diminution of the size of the esophagean hiatus. Total time of intervention: two hours (30m for the cholecystectomy and one hour and thirty minutes for the myomectomy). Postoperative period: uneventful. Disappearance of the disphagia was observed. Radiologic transit control with water-soluble contrast at 4th post-operative day: good passage. Diagnosis from laboratory of pathology: conjunctive tumour formed by muscle non-striated cells: leiomyoma. The patient was re-examined on the two-month postoperative follow-up. General conditions were good and there were no complain of dysphagia. Neither there were any symptoms of gastro-esophageal reflux

Valor prognóstico da morfometria no carcinoma folicular da tireóide / Prognostic value of morphometry in follicular thyroid carcinoma

Tendo em vista a escassa literatura a respeito de correlação entre a histometria dos carcinomas de tireóide e o prognóstico desses tumores, objetivou-se, nesta pesquisa, correlacionar parâmetros histométricos do carcinoma folicular da tireóide com o tempo de sobrevida após tratamento. Em carcinomas foliculares da tireóide de 60 pacientes foram realizadas medições no núcleo das células malignas (área, perímetro, diâmetro máximo, diâmetro mínimo) e calculados índices (razão dos diâmetros, fator de forma e índice de atividade mitótica). Esses parâmetros foram correlacionados com o tempo de sobrevida. Por outro lado, parâmetros clínicos e patológicos (sexo, idade, extensão local, comprometimento linfonodal, grau de diferenciação celular) também foram correlacionados com o prognóstico. Foram realizados cálculos autuariais e análise estatística uni e multivariada. Constatou-se que a sobrevida foi significantemente influenciada por variáveis clínicas e patológicas, tais como a idade dos pacientes e a extensão loco-regional do tumor. Nenhuma correlação estatisticamente significante pôde ser demonstrada entre parâmetros morfométricos e sobrevida, apesar dos resultados sugerirem associação entre o tamanho do núcleo das células malignas e a agressividade do tumor