Exaggerated blood pressure response during the exercise treadmill test as a risk factor for hypertension.

Exaggerated blood pressure response (EBPR) during the exercise treadmill test (ETT) has been considered to be a risk factor for hypertension. The relationship of polymorphisms of the renin-angiotensin system gene with hypertension has not been established. Our objective was to evaluate whether EBPR during exercise is a clinical marker for hypertension. The study concerned a historical cohort of normotensive individuals. The exposed individuals were those who presented EBPR. At the end of the observation period (41.7 months = 3.5 years), the development of hypertension was analyzed within the two groups. Genetic polymorphisms and blood pressure behavior were assessed as independent variables, together with the classical risk factors for hypertension. The I/D gene polymorphism of the angiotensin-converting enzyme and M235T of angiotensinogen were ruled out as risk factors for hypertension. EBPR during ETT is not an independent influence on the chances of developing hypertension. No differences were observed between the hypertensive and normotensive individuals regarding gender (P = 0.655), skin color (P = 0.636), family history of hypertension (P = 0.225), diabetes mellitus (P = 0.285), or hypertriglyceridemia (P = 0.734). The risk of developing hypertension increased with increasing body mass index (BMI) and advancing age. The risk factors, which independently influenced the development of hypertension, were age and BMI. EBPR did not constitute an independent risk factor for hypertension and is probably a preclinical phase in the spectrum of normotension and hypertension.

Exaggerated blood pressure response during the exercise treadmill test as a risk factor for hypertension

Exaggerated blood pressure response (EBPR) during the exercise treadmill test (ETT) has been considered to be a risk factor for hypertension. The relationship of polymorphisms of the renin-angiotensin system gene with hypertension has not been established. Our objective was to evaluate whether EBPR during exercise is a clinical marker for hypertension. The study concerned a historical cohort of normotensive individuals. The exposed individuals were those who presented EBPR. At the end of the observation period (41.7 months = 3.5 years), the development of hypertension was analyzed within the two groups. Genetic polymorphisms and blood pressure behavior were assessed as independent variables, together with the classical risk factors for hypertension. The I/D gene polymorphism of the angiotensin-converting enzyme and M235T of angiotensinogen were ruled out as risk factors for hypertension. EBPR during ETT is not an independent influence on the chances of developing hypertension. No differences were observed between the hypertensive and normotensive individuals regarding gender (P = 0.655), skin color (P = 0.636), family history of hypertension (P = 0.225), diabetes mellitus (P = 0.285), or hypertriglyceridemia (P = 0.734). The risk of developing hypertension increased with increasing body mass index (BMI) and advancing age. The risk factors, which independently influenced the development of hypertension, were age and BMI. EBPR did not constitute an independent risk factor for hypertension and is probably a preclinical phase in the spectrum of normotension and hypertension.

Revising the M235T polymorphism position for the AGT gene and reporting a modifying variant in the Brazilian population with potential cardiac and neural impact.

There is a growing need to curate the overwhelming amount of sequencing data which is available in many public databases. For instance, new information shows that the M235T polymorphism at the angiotensinogen gene (AGT) is actually positioned at the position corresponding to the amino acid 268 and not 235. This polymorphism is filled as rs699 in the NCBI SNP database and results in the synthesis of a threonine (T) instead of a methionine (M). It has been widely studied and associated as an important risk factor for several vascular and neuropsychiatric conditions. We faced this new situation during the targeted sequencing of 360 chromosomes from Brazilian subjects studied for the M235T polymorphism, leading to the identification of a novel variation (rs141900991). This report explores the potential impact of such a dinucleotide variation, which promotes the change of alanine (A) to serine (S) at the AGT protein structure (A237S). Considering the previous M268T variation at the four possible haplotypes combined (MA, MS, TA and TS), we performed a comparative hydrophobicity simulation, using the Kyte-Doolittle algorithm, available at the CLB Bio workbench, in the four possible haplotypes. Additional simulations were performed using the programs PolyPhen, I-Mutant and SIFT, in order to evaluate the pathogenicity of both mutations. The predicted hydrophobicity decreases of a similar magnitude, with both MS and TA haplotypes, but the presence of both variations induces a major decrease in hydrophobicity, suggesting a cumulative effect, with possible modifying effect since that this variation per se would limit the hydrophobicity range and the latter chances in finding significant phenotype differences. A better characterization of this kind of variant is particularly important because the current genome wide scan analyses in complex disorders with cardiac or neural etiology are not generating reliable findings, especially if we consider the huge investment with such approach. Additional and unknown variations like this one, with potential modifying effect, might be more common than previously expected.

Clinical and pathologic prognostic factors for curative resection for pancreatic cancer.

BACKGROUND: Pancreatic cancer is the fifth leading cause of cancer-related deaths in the world. Operative resection is the only therapeutic option with curative potential for this disease. OBJECTIVE: The aim of the present study was to correlate clinical and pathologic parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma. METHODS: Surgical resection with curative intent (R0 and R1 resections) was performed in 65 pancreatic cancer patients between 1990 and 2006. The overall results of surgical treatment were retrospectively analyzed and compared with the clinicopathologic features of these patients. RESULTS: Pylorus-preserving pancreatoduodenectomy was performed in 37 patients (56.9%), classic resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. The inhospital mortality was 5% (three patients). Postoperative complications occurred in 28 patients (43%). Mean survival and five-year survival rate after curative resection were 27 months and 9.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and involvement of resection margin were significant prognostic factors on univariate analysis. Multivariate analysis showed tumor differentiation and neural invasion as prognostic factors. CONCLUSION: Patients with pancreatic cancer, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.

Surgical and interventional treatment of chronic pancreatitis.

The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.

Radial endoscopic ultrasound and spiral computed tomography in the diagnosis and staging of periampullary tumors.

BACKGROUND AND STUDY AIMS: The early detection and accurate staging of pancreatic and ampullary cancer is of utmost importance for the achievement of surgical radical treatment. The aim of this study was to assess prospectively the role of endoscopic ultrasonography (EUS) in detection and staging of pancreatic and ampullary cancer, comparing its results to those obtained with spiral computed tomography (SCT). PATIENTS AND METHODS: Sixty-one patients with suspected pancreatic and ampullary tumors were included, 46 (75, 4%) of whom presented with obstructive jaundice. Patients underwent EUS and SCT within a 7-day period. Examiners were unaware of the previous imaging results, except conventional echography. Image interpretation was compared to surgical and histopathological findings. RESULTS: Fifty-six (91, 8%) patients were surgically explored. Clinical follow-up and/or tissue diagnosis determined the correct diagnosis in the remaining five patients. Pancreatic cancer and ampullary cancer were observed in 29 (47, 6%) and 10 (16, 4%) patients, respectively. Chronic pancreatitis and choledocholithiasis were the most common diagnosis in patients with non-neoplastic disease. EUS was more effective than SCT for the definition of the final diagnosis in patients with obstructive jaundice (87.0 vs. 67.4%, p = 0.04). Both exams were equally effective for detecting pancreatic cancer but EUS predicted more accurately the involvement of portal-mesenteric axis by the tumor (87.0 vs. 67.4%, p = 0.04). EUS was particularly useful in the diagnosis of cancer of papilla of Vater. CONCLUSION: In patients with pancreatic adenocarcinoma without unequivocal signs of distant metastatic disease, EUS is more accurate than SCT to predict venous involvement by the tumor. EUS is superior to SCT to detect ampullary adenocarcinoma. Both methods are equally ineffective to detect nodal involvement in pancreatic and ampullary cancer.

Pancreatic head tumors with portal vein involvement: an alternative surgical approach.

BACKGROUND/AIMS: One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion. METHODOLOGY: Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step. RESULTS: Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality. CONCLUSIONS: This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.

Insulinoma: diagnostic strategies and surgical treatment. A 22-year experience.

BACKGROUND/AIMS: The efficacy of preoperative localization methods and the results of the surgical treatment of insulinoma were studied. METHODOLOGY: Fifty-nine patients referred for surgical treatment were studied and the results of the diagnostic tools for tumor localization were compared with findings at surgical intervention. The influence of the type of surgical procedure in the immediate and late postoperative course was also studied. RESULTS: Ultrasonography had a sensitivity of 30%, computed tomography 25%, angiography 54%, portal vein sampling 94%, endoscopic ultrasonography 27% and magnetic resonance 17%. Intraoperative palpation localized 98.2% of the tumors and by the addition of intraoperative echography, all lesions were identified. In 55 patients with benign lesions, 22 enucleations, 25 distal pancreatectomies, 7 pancreatectomies plus enucleation and one duodenopancreatectomy were performed. Malignant tumors were treated by pancreatic resection, postoperative hepatic artery embolization and systemic chemotherapy. There was no postoperative mortality. Pancreatic fistula was the most common complication. Three patients who underwent distal pancreatectomy developed late diabetes (9.3%). CONCLUSIONS: Extensive preoperative investigation, mainly with invasive methods, is not indicated and by combining intraoperative palpation and echography most of the cases can be adequately dealt with. Preservation of pancreatic tissue with enucleation and preservation of the spleen are the best choice for treatment of benign insulinomas.

Effect of platelet-activating factor antagonists (BN-52021, WEB-2170, and BB-882) on bacterial translocation in acute pancreatitis.

Bacterial translocation is an important source of pancreas infection in acute pancreatitis. The effect of platelet-activating factor (PAF) in the pathogenesis of acute pancreatitis has been proved in various studies. The aim of this study was to determine whether potent PAF antagonists influence bacterial translocation in acute pancreatitis. Acute pancreatitis was induced in 62 Wistar rats by injection of 2.5% sodium taurocholate into the biliopancreatic duct. The rats treated with PAF factor antagonists received intravenous injection of WEB-2170 (10 mg/kg), lexipafant (5 mg/kg), and BN-52021 (5 mg/kg) 30 minutes before induction of acute pancreatitis. Six hours after induction of acute pancreatitis, bacteriologic cultures and histologic scoring of tissues were performed. There was a statistically significant reduction in bacterial translocation to the mesenteric lymph nodes and liver but not to the pancreas of the rats treated with PAF antagonists. No significant increase in the intestinal bacterial population of any group was found. There were no statistical differences between the pancreatic histologic scores of the groups. PAF antagonists reduced bacterial translocation to distant sites other than the pancreas, preventing the bacterial dissemination that occurs in the early phase of acute pancreatitis and may have beneficial effects on the evolution of this disease.

Distal pancreatectomy without splenectomy and with preservation of splenic vessels.

BACKGROUND/AIMS: Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. METHODOLOGY: Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas. RESULTS: The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality. CONCLUSIONS: Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.

Preoperative diagnosis of pancreatic leiomyosarcoma.

BACKGROUND: The low incidence of pancreatic leiomyosarcoma is responsible for the small number of cases correctly diagnosed preoperatively, the tumor being frequently confused with benign pancreatic lesions. RESULTS: We describe a symptom free 52-yr-old male bearing an abdominal mass incidentally found at physical examination. Imaging techniques revealed a nonhomogenous large mass at the head of the pancreas that dislodged the portal vein and the superior mesenteric vein. Increased metabolic activity in the tumor area demonstrated by 18F-fluorodeoxyglicose positron emission tomography scan allowed the diagnosis of a malignant lesion. The patient was operated on and a pylorus preserving pancreatoduodenectomy performed. The pathology diagnosis was a low grade leiomyosarcoma. Immunohistochemistry revealed positivity for vimentin and smooth muscle specific actin. The clinical course was uneventful after 2 yr follow-up. CONCLUSION: Pancreatic leiomyosarcoma may be preoperatively diagnosed by image techniques and differentiated from benign lesions by means of fluorodeoxyglicose positron emission tomography scanning (FDGPET).

A new technique of gastroenterostomy for palliative treatment of pancreatic head carcinoma.

BACKGROUND/AIMS: Most of the patients with pancreatic cancer can be only palliatively treated. Although 30% of the patients submitted to palliative biliary bypass will require further treatment for duodenal obstruction, prophylactic gastric bypass still remains a controversial issue in the management of unresectable pancreatic head carcinoma. The main disadvantage of current techniques of gastrojejunostomy is postoperative vomiting due to impaired gastric motility and circulus vitiosus through the nonobstructed duodenum. A new technique of prophylactic gastrojejunostomy is described herein as an attempt to obviate these complications. METHODOLOGY: An antecolic isoperistaltic gastrojejunostomy was fashioned at the gastric mid-body above the angulus. The afferent limb was partitioned close to the gastrojejunostomy and a Braun type entero-enterostomy constructed joining the afferent and the efferent limbs. Following the gastrojejunostomy a Roux-en-Y choledochojejunostomy was performed. RESULTS: In 19 patients consecutively submitted to this procedure no postoperative mortality or complications occurred. Nasogastric suction was interrupted at postoperative day 3 and oral feeding resumed on the next day. Neither early nor late postoperative vomiting was observed. CONCLUSIONS: These encouraging preliminary results suggest that this procedure may have its place in the palliative treatment of pancreatic head carcinoma.

Surgical treatment of cicatricial biliary strictures.

BACKGROUND/AIMS: Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures. METHODOLOGY: The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used. RESULTS: Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications. CONCLUSION: Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.

[Surgical treatment of insulinoma: study of 59 cases]. / Tratamento cirúrgico dos insulinomas--Estudo de 59 casos.

UNLABELLED: After establishing the diagnosis of an insulinoma the next step is its localization in order to perform the most suitable management approach. PURPOSE: To evaluate the methods used for the diagnosis of insulinoma and the localization of its site as well as the results of the surgical treatment. METHODS: Fifty nine consecutive patients with pancreatic insulinomas were studied. The discriminative power of the preoperative investigations in the localization of insulinomas was analysed. Special attention was focused to the intra operative methods of tumor localizations. The early and late results of the surgical treatment were also investigated. RESULTS: There were 55 benign cases and 4 malignant tumors. Preoperative localization was attempted by using ultrasonography (positive in 28.1%) CT imaging (positive in 25%), selective arteriography (positive in 54.1%), endoscopic ultrasonography (positive in 27.2%) and assay of portal plasma insulin levels (positive in 94.4%). In 54/55 cases (98.2%) the tumors were identified intraoperatively by palpation. By addition of intraoperative ultrasonography all lesions were identified and successfully removed without mortality. Five patients had multiple endocrine neoplasias all with multiple lesions in the pancreas. In patients with benign lesions 29 enucleations and 32 resections were performed. Pancreatic fistulas were the most common complication (29/59). Excluding the patients with malignant lesions the recovery rate was 98.1%. Three patients who underwent corporo caudal pancreactectomy developed diabetes. CONCLUSIONS: The preoperative localization is not necessary, since a combination of palpation and intraoperative ultrasonography can deal with most cases. Enucleation when possible is the best choice for benign lesions.

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.

Pyogenic liver abscess: the role of surgical treatment.

MATERIALS AND METHODS: We present an analysis of 48 patients with pyogenic liver abscess (PLA) that were treated according to a protocol between 1975 and 1993. In this period, 35 patients with PLA were treated by surgical drainage (SD). The indication for surgical treatment of the abscess were patients in septic conditions, underlying intra-abdominal surgical disease and the failure/contraindication of other therapeutic methods. Thirty-one patients were submitted to surgical treatment as the initial procedure and four patients unsuccessfully treated by percutaneous drainage, underwent SD. RESULTS: The surgical approach was indicated in patients with severe disease and presented 91.5% of good results, and a mortality rate of 8.5%. CONCLUSIONS: These results suggest that surgical treatment is a good alternative as a first step not only for the treatment of the primary cause of the abscess but also in septic patients with severe disease where a delay in adequate drainage, frequent in percutaneous management, can lead to high morbidity and mortality rates.

[Complications of chronic pancreatitis in São Paulo (Brazil)]. / Complicações das pancreatites crônicas em São Paulo.

Chronic Pancreatitis (CP) presents distinctive characteristics in different geographical areas. With the purpose of evaluating the clinical characteristics, particularly in relation to the frequency and etiopathogeny of the complications in São Paulo, in comparison to other centers, 545 patients with this disease were analyzed, retrospectively, 493 (90.5%) of these patients were males and 52 (9.5%) females, with ages ranging from 8 to 88 (38.2 +/- 9.3 years). The diagnosis of CP was based on criteria previously adopted by the Pancreas Group of Gastroenterology Studies of the Medical School of São Paulo. The principal etiologic factors were represented by: chronic alcoholism in 509 of the 545 patients (93.4%), hereditary factors in four (0.7%), malnutrition in three (0.5%), metabolic alterations in three (0.5%) and obstruction to the pancreatic flow in two patients (0.3%). In 24 (4.4%) of the 545 patients, the etiologic factor could not be established, due to the idiopathic nature of the disease. Of the 509/545 patients (93.4%) presenting chronic ethylism, alcoholic consumption was characterized by: a) mean age alcoholic consumption was initiated: 19.5 +/- 6.5 years; b) mean daily alcoholic consumption in grams of pure ethanol: 358.6 +/- 282.0 g/d; c) mean time of alcoholic consumption: 19.8 +/- 8.8 years, and d) mean age of the appearance of clinical symptoms: 34.9 +/- 9.8 years. The clinical complications were always investigated in accordance with the pre-established protocol; the principal complications observed were represented by: gastrointestinal compression (3.3%), jaundice (24%), cysts (35.9%), cavity effusions (13.3%), pancreatic necrosis (4.7%), abscesses (3.6%), digestive hemorrhage of pancreatic origin (2.3%) and fistulae (1.1%). The incidence of these complications, particularly cysts, cavity effusions and pancreatic necrosis, was greater in the patients studied than in those observed in other regions, probably due to the presence of more intense and frequent anatomopathologic lesions found in these patients, possibly resulting from the greater consumption of alcohol compared to patients with this disease in other centers. The etiopathogenic mechanisms for the complications were individually analyzed and interpreted.

[Biliary fistula after elective conventional cholecystectomy]. / Fístula biliar após colecistectomias convencionais eletivas.

The use or not of drainage after elective cholecystectomy has been recently studied, and we will discuss the real incidence of the subhepatic biliary collection and its clinical significance. In this sense, we studied 20 patients with a mean age of 45 years (4 male and 16 female), submitted to elective cholecystectomy according to selective techniques patterned by our group, where we realized ligature of all vessels of the gallbladder bed, and subhepatic drainage. These patients receibed 99 mTc-DISIDA at the moment we closed the abdomen, and in a period of 24 and 48 hours we studied its presence in the subhepatic bed and in the drainage material. All the patients had not post-operative complications and none biliary drainage or subhepatic collection scanned. We concluded that using our preconized techniques, the subhepatic drainage is unnecessary after elective cholecystectomy.

[Results of conventional cholecystectomy. Experience in a university hospital]. / Resultados da colecistectomia convencional. Experiência em hospital universitário.

The experience with open cholecystectomy in an university affiliated hospital is documented in this report. We studied retrospectively 221 patients operated between 1987 and 1992, type of surgery, morbidity and mortality were analyzed. There were 171 (77.3%) cholecystectomy alone and 50 (22.7%) cholecystectomy with other biliary surgery (BS). Pulmonary, urinary and wound complications were the most common. Overall incidence of complications was 7.2%. For patients with cholecystectomy alone morbidity was 3.5% and for patients with BS morbidity was 20% (p < 0.002). There were no mortality in this group of patients.

[Distal pancreatectomy with conservation of the spleen]. / Pancreatectomia corpo-caudal com preservação de baço.

Conventional resection of the body and tail of the pancreas usually involves splenectomy. There are evidence that spleen removal can lead to septic and hematological complications and should, therefore, be avoided when possible. Distal pancreatectomy with spleen conservation has been described by specialized centers with good results. This report describes our experience in 8 cases with conservation of the spleen during the resection of the body and tail of the pancreas. The technique has been applied in patients with pancreatic neuroendocrine tumors (n = 4), cystic tumors (n = 3) and cystic-papillary tumor (n = 1) with no complications and good late results in all cases.