Reconstrução cirúrgica da estenose cicatricial de vias biliares pós-colecistectomia / Surgical reconstruction of post-cholecistectomy cicatricial biliary stenosis

OBJETIVO: Avaliar uma série de casos de estenose cicatricial de vias biliares pós-colecistectomia submetidos à reconstrução cirúrgica. MÉTODOS: Foi realizado estudo retrospectivo de 27 pacientes submetidos à reconstrução cirúrgica da via biliar por estenose cicatricial. O tipo de colecistectomia que resultou na lesão, idade e sexo, sinais e sintomas, o momento do diagnóstico, se precoce ou tardio, presença de cirurgias prévias na tentativa de reconstruir a árvore biliar, classificação das estenoses, e tipo de operação empregada para o tratamento da injúria foram analisados. RESULTADOS: Vinte e seis lesões ocorreram durante laparotomia e uma durante vídeolaparoscopia. Dezesseis pacientes (59%) tiveram as lesões diagnosticadas no transoperatório ou nos primeiros dias de pós-operatório, sete (26%) dos quais já submetidos à reoperação no hospital de origem, evoluindo mal; nove pacientes desse grupo (33%) não tinham reoperação. Onze pacientes (41%) apresentaram a forma clássica de estenose cicatricial, sem acidentes transoperatórios aparentes, com desenvolvimento de obstrução biliar tardia. Todos os pacientes foram submetidos à anastomose hepático-jejunal em "Y" de Roux, sendo que em dois casos os ductos hepáticos direito e esquerdo foram implantados separadamente na alça exclusa de jejuno. Vinte e seis pacientes (96,3%) evoluíram bem inicialmente, um paciente teve fístula biliar e foi a óbito. Uma paciente com bom resultado inicial apresentou recidiva da anastomose, cirrose secundária e está aguardando transplante hepático. CONCLUSÃO: A maioria das lesões foi diagnosticada durante a colecistectomia ou nos primeiros dias de pós-operatório, sete pacientes já tinham sido operados na tentativa de reconstruir o trato biliar. A hepaticojejunostomia em "Y" de Roux empregada mostrou-se segura e efetiva em recanalizar a via biliar a curto e longo prazos.

OBJECTIVE: To evaluate a series of cases of cicatricial stenosis of the biliary tract after cholecystectomy undergoing surgical reconstruction. METHODS: We conducted a retrospective study with 27 patients who underwent surgical reconstruction of the biliary tree for cicatricial stenosis. We analyzed the type of cholecystectomy that resulted in injury, age, gender, signs and symptoms, time of diagnosis, early or late, presence of previous surgery in an attempt to reconstruct the biliary tree, classification of stenosis and type of operation used for treatment of the injury. RESULTS: Twenty-six injuries occurred during a laparotomy and one during laparoscopy. Sixteen (59%) lesions were diagnosed intraoperatively or within the first postoperative day, seven (26%) havinh been submitted to reoperation at the local hospital, with poor results; nine patients in this group (33%) had no reoperation. Eleven patients (41%) had the classic form of cicatricial stenosis, without apparent intraoperative accidents and late development of biliary obstruction. All patients underwent Roux-en-Y hepatic-jejunal anastomosis; in two cases the right and left hepatic ducts were implanted separately in the excluded jejunal loop. Twenty-six patients (96.3%) had no early complications; one patient had biliary fistula and died. One patient presented with stenosis recurrence, secondary cirrhosis and is awaiting liver transplantation. CONCLUSION: Most injuries were diagnosed during cholecystectomy within the first postoperative days; seven patients had been reoperated in an attempt to reconstruct the biliary tract. Roux-en-Y hepaticojejunostomy proved safe and effective in draining the bile duct in the short and long term.

O retalho pleural na perfuração do esôfago torácico / The pleural wrap in the thoracic esophageal perforation

The thoracic esophageal perforations frequently complicate with fistula when submitted to primary suture. The use of autogenous tissues, like pleura, to reinforce the primary suture has proved to be useful in reduce the incidence of fistulas or at least the severity of the leaks in case they occur. The mortality has reduced too, consequently. A case of an extensive esophageal perforation is presented, where the use of pleural wrap to reinforce the esophagorrafy was very important to contain the leak and to permit a good evolution of the patient.

Perfuração de esôfago: análise de 11 casos / Esophageal perforation: analysis of 11 cases

OBJETIVO: Avaliar o tratamento de 11 pacientes com perfuração de esôfago. MÉTODO: Foram avaliados 11 casos de perfuração esofágica tratados pelo autor no Hospital Getúlio Vargas, no período de setembro de 2001 a março de 2008. RESULTADOS: Em seis pacientes (54,5 por cento), a perfuração era no esôfago cervical, quatro (36,4 por cento) no torácico e um (9,1 por cento) no abdominal. A etiologia da lesão foi corpo estranho em cinco casos, arma branca em dois e os outros foram por arma de fogo, dilatação endoscópica, ingestão de substância cáustica e trauma contuso. Diagnóstico e tratamento nas primeiras 24 horas ocorreu em três (27,3 por cento) pacientes e após 24 horas em oito casos (72,7 por cento). O tratamento conservador foi instituído para dois (18,2 por cento), que evoluíram bem e o cirúrgico para nove (81,9 por cento), dentre os quais houve dois óbitos. CONCLUSÃO: a perfuração esofágica é grave, mas um tratamento precoce e adequado pode resultar na sobrevida da maioria dos pacientes.

BACKGROUND: We evaluated the treatment of 11 patients with esophageal perforation. METHODS: A retrospective clinical review was undertaken of 11 cases of esophageal perforation treated by the author in the Getúlio Vargas Hospital, between September/2001 and March/2008. RESULTS: In six patients (54.5 percent), the site of the esophageal perforation was cervical esophagus, four (36.4 percent) at the thoracic portion and one (9.1 percent) at the abdominal segment. The lesion was induced by foreign bodies in five cases, stab wound in two and the others were gunshot wound, endoscopic instrumentation, ingestion of caustic substance and blunt abdominal trauma. Diagnosis and treatment were performed within the first 24 hours in three (27.3 percent) patients and after 24 hours in eight patient (72.7 percent). Conservative treatment was employed in two (18.2 percent) patients, with good outcome. Surgical treatment was performed in nine (81.9 percent) patients, with two deaths. CONCLUSIONS: Esophageal perforation is a serious condition, but an early and appropriate treatment can result in the survival for the majority of the patients.

Síndrome de Peutz-Jeghers: relato de caso / Peutz-Jeghers syndrome: case report

Peutz-Jeghers syndrome (PJS) is a dominant autosomal inherited disorder characterized by intestinal hamartomatous polyps in association with mucocutaneous melanocytic maculae. This syndrome is rare, and the frequency reaches from 1 in 60,000 to 1 in 300,000 people in the USA. The symptom presentations vary greatly in this disease. Some patients require minor clinical treatment while others undergo many hospitalizations and surgical treatments. In addition, patients with PJS have an increased risk for developing a variety of malignant tumors. The aim of the present study was to report one case studied of Peutz-Jeghers syndrome.

Esofagectomia na perfuração esofágica com diagnóstico tardio / Esophagectomy for the esophageal perforation with delayed diagnostic

Esophageal perforations are related to high mortality rates, especially if there is a delayed diagnostic and treatment. We report an esophageal perforation caused by caustic ingestion, in a suicidal attempt, successfully treated by esophagectomy after a long period of misdiagnosis that lead to infectious complications.

Manifestação de hemangioendotelioma hepático em adulto / Hepatic hemangioendothelioma in adult

Hepatic hemangioendothelioma is the most frequent hepatic tumor in infancy, but rarely detected in adults. This tumor can cause vascular lesions that can act as arteriovenous fistulas and produce life-threatening high output congestive heart failure with respiratory compromise. We report a case of a 35 years-old woman who developed nausea, vomiting, weight lost and abdominal mass in which the pathological examination of the hepatic lesion showed a infantile hepatic hamangioendothelioma. This is the third case in adult patients described in the literature.

Anastomose bílio-digestiva sem descompressão gástrica / Bilio-enteric anastomosis without gastric decompression

OBJETIVO: O objetivo deste estudo foi avaliar a ausência da descompressão gástrica como método seguro em pacientes submetidos a papilotomia transduodenal, anastomose colédoco-duodenal ou a hepático-jejunostomia em Y de Roux. MÉTODO: Trinta e quatro pacientes foram submetidos à anastomose bíliodigestiva transduodenal, anastomose colédoco-duodenal ou a hepático- jejunostomia em Y de Roux sem descompressão gástrica com sonda. RESULTADOS: Vinte e quatro (70 por cento) pacientes não apresentaram nenhum episódio de vômito. Não houve casos de distensão abdominal ou vômitos incoercíveis que obrigasse o uso da sonda no pós-operatório. Nenhum paciente apresentou deiscência da duodenotomia, das anastomoses ou da parede abdominal. Não houve casos de complicações pulmonares. CONCLUSÕES: O resultado do presente estudo sugere que a papilotomia transduodenal, a coledocoduodenostomia e a hepático-jejunostomia em y de Roux sem SNG não têm incidência aumentada de complicações. Além disso, os pacientes não são expostos ao risco da utilização da sonda.

BACKGROUND: Nasogastric intubation (NGI) has been used after abdominal surgery to prevent complications. However, the classic concept that gastric decompression prevents complications is being questioned. The aim of this study was to evaluate the lack of gastric decompression as a safe method in patients undergoing transduodenal papilotomy, choledocal-duodenal anastomosis or hepatic-jejunostomy Roux-en-Y. METHODS: Twenty-four patients were submitted to transduodenal papilotomy (10), choledocal-duodenal anastomosis (10) or hepatic-jejunostomy Roux-en-Y (4) without gastric decompression using tube. RESULTS: Sixteen (66 percent) patients didn’t present vomiting. There was no postoperative abdominal distension or vomiting. There was no case of dehiscence of duodenostomy, anastomosis or abdominal wall. None presented pulmonary complications. CONCLUSION: Our study suggests that transduodenal papilotomy and choledocal-duodenal anastomosis without NGI are not associated to postoperative complications. Futhermore, this approach avoids the risk of using NGI, reducing hospital costs.

Divertículo de Zenker: relato de três casos / Zenker's diverticula: report of three cases

Pharyngoesophageal diverticula are epithelial-lined pouches that protrude from the esophageal lumen. They were studied by Zenker in 1878,receiving the denomination of Zenker's diverticulum. They are false diverticula since they don't have all layers of the esophageal wall. Although they are most common esophageal diverticula . Their incidence is of 3 percent of the patient presenting dysphagia. Current , there are several therapeutic modalities, from dilatation of the esophagus to surgery with resection of the diverticulum. The report refers to three patients with Zenker's diverticulum who underwent conventional surgical treatment.

Cisto de colédoco em adulto / Choledochal cyst in adult

Choledochal cyst is a rare congenital malformation of the biliary tree, and aproximately 25 por cento of them are diagnosed in adults. Appropriate surgical management of these lesions depends on the anatomic site and extension of the cystic process. The recognized association of the bile duct cysts with hepatobiliary malignant disease has important surgical implications. Total cyst removal and cholecistectomy with Roux-en-Y hepaticojejunostomy was performed in a 47 year old female with a common bile duct cyst tipe 1 postoperative period was uneventful. A review of literature is presented