Off label pharmacological therapy in patients with short bowel syndrome.

BACKGROUND: Short bowel syndrome is a disabling disease requiring long-term nutritional support and ancillary drugs. Aiming to analyze the most commonly prescribed drugs, a retrospective analysis was conducted is an outpatient cohort. PATIENTS AND METHODS: Stable patients (N= 37, 59.5% males, age 51.1 ± 20.1 years, body mass index 20.1 ± 7.9 kg/m2) with three or more appointments in the Outpatient Service during the last 18 months were retrospectively analyzed. regarding oral pharmacologic prescriptions. Medications were classified as on label or off label. RESULTS: A total of 257 oral prescriptions were retrieved from computer files, encompassing 17 different preparations. The majority was employed on label however 28.8% (74/257) were classified as off label and scrutinized with regard to indications. The main categories were pharmacologic modulators of gastrointestinal secretions and motility, along with antibiotics. Virtually all patients required one or more of such drugs, without differences regarding demographic or clinical variables. Adverse effects or premature drug discontinuation were not observed. CONCLUSIONS: This is the first study to our knowledge highlighting the importance of adjuvant drugs, particularly with unconventional indications, in the management of short bowel syndrome. Antidiarrheic agents, pancrelipase micropellets, antacids and antibiotics represented the most relevant off label prescriptions for this population.

Prevention of neoplastic port site implants in laparoscopy: an experimental study.

Enthusiasm about the application of videolaparoscopy to oncologic diseases has been limited by the growing number of port site implants. Adult Wistar rats were submitted to 6-7 mm Hg carbonic gas pneumoperitoneum. Rats were randomly divided into two groups: group I rats with tumor (200,000 viable cells of Walker tumor) and group 11 rats with no tumor. The pneumoperitoneum was deflated after 30 min. Group I was further randomized into five groups: no treatment; or abdominal irrigation with saline, heparin, chemotherapy (doxorubicin), or chemotherapy associated with heparin. After a period lasting no more than 18 days, the abdominal wall and intraperitoneal organs macroscopically affected were studied histologically. Chemotherapy groups had no port site implants and were significantly different (p < 0.05) than the no treatment, saline, and heparin solution groups, which had incisional implants at frequencies of 100%, 85.7%, and 82.5%, respectively. Intraperitoneal irrigation with chemotherapy solution was effective in preventing incisional implants in this animal model.

Gastro-esophageal isoperistaltic bypass in the palliation of irresectable thoracic esophageal cancer.

METHODS: The authors retrospectively review 22 patients with irresectable esophageal cancer in whom an isoperistaltic substernal gastric esophagogastric bypass was performed. RESULTS: After the operation eighteen patients (82%) regained normal swallowing. Seven patients developed anastomotic stenosis that was successfully treated in six by surgery or endoscopic dilatation. Two patients evolved with cervical fistulae until their death. As a whole, there was a statistically significant improvement in swallowing capability (p = 0.0352). Seventeen patients (77%) had postoperative complications, the most common being cervical fistulae (in 13.59%), pneumonia (in 10.45%) and anastomotic stenosis (in 7.32%). Postoperative morbidity was significantly associated with preoperative diseases and ASA class III (p < 0.05). There were three postoperative deaths (14%). Postoperative mortality was significantly related to severe malnutrition and preoperative associated disease (p < 0.05). CONCLUSIONS: The conclusion is that the procedure has acceptable morbidity and mortality for the population under consideration, permitting palliation of dysphagia in the majority of cases.

Endoscopic papillotomy under ultra-sonographic control.

A new endoscopic method for performing endoscopic sphincterotomy is described. Only after correct positioning of the papillotomy device has been ascertained can papillotomy be carried out. We have used ultra-sonographic examination to confirm the correct placement of the papillotomy device. This technique was first employed on a pregnant patient in 6-13-1988. After that we performed this procedure in another twelve patients. We believe it is an easy procedure and perhaps may be used for all patients with common bile duct stones of less than 1.2 cm of diameter without other bilio-pancreatic pathological condition.

Histopathology of the common bile duct in choledocholithiasis.

The histology of the common bile duct was studied in 45 patients with choledocholithiasis and/or papillitis and compared with a control group of ten cadavers without hepatic or biliary disease. Choledochitis was diagnosed in 44. Only one patient presented a histologically normal duct. The inflammatory process was characterized by proliferation of connective tissue and loss of elastic fibers, cellular infiltration of lymphocytes and polymorphonuclear leukocytes, and atrophic dilatation or hyperplasic glandular changes. Choledochitis was divided in two types: chronic and acute-chronic, and according to the intensity of the inflammatory process was also classified in slight, moderate or severe. No correlation was found between choledocholithiasis and/or papillitis and type and intensity of choledochitis.

Regeneration of esophageal epithelium in the presence of gastroesophageal reflux.

The esophageal mucosa in twelve dogs was excised from the distal third of the esophagus together with a surgical procedure to provoke gastroesophageal reflux. A longitudinal segment containing all the layers of the wall of the esophagogastric junction was removed intraoperatively in all dogs. It was determined that in this segment, the transition of the columnar and squamous epithelia and the apex of the inferior sphincter of the esophagus, which is perfectly individualized in the dog except for few variations, were at the same level. During the postoperative period, the dogs were randomly divided into two groups according to the time of sacrifice. Group I was killed after 30 days and Group II after 60. Serial sections of the autopsy specimen were taken at the level of the esophagogastric junction, in order to determine the way in which the esophageal epithelium regenerates in the presence of gastroesophageal reflux. The apex of the inferior sphincter of the esophagus was used as a fixed parameter of the esophagogastric transition, even in the absence of its epithelial lining. Postoperatively the dogs presented varying lengths of the inferior third of the esophagus relined with columnar epithelium. The epithelium originates either from the gastric epithelium itself, or from the ducts of the submucosal glands of the esophagus. The histologic aspect of the regenerated columnar epithelium varied from simple columnar epithelium to a well-differentiated epithelium resembling gastric mucosa. These studies reinforce the concept that columnar epithelium lining the terminal esophagus may be acquired due to reepithelization in an acid medium, of a previously injured esophageal epithelium.

Esofago de Barrett - conceituacao atual e analise critica da interpretacao de sua etiologia e fisiopatologia. / Barret esophagus - current concepts and critical analysis of the interpretation of its etiology and physiopathology

Os autores realizam um profundo estudo da literatura desde a descricao do esofago revestido por epitelio cilindrico em 1950 por Barrett, ate os nossos dias. Analisam as teorias congenita e adquirida para o fenomeno, - concluindo que embora a forma congenita possa ocorrer e a adquirida que contribui com o maior contingente de casos, bem como a que possui maiores implicacoes praticas. A forma adquirida seria ainda associada a esofagite de refluxo, segundo a conclusao dos autores. Outros aspectos de grande importancia sao abordados, tais como a evolucao do esofago de Barrett apos a supressao cirurgica do refluxo gastro-esofagico e a possibilidade de transformacao carcinomatosa que ocorre em 20% dos casos, segundo a revisao realizada. Com esta publicacao os autores procuram aclamar as ideias e a organizar os conceitos referentes ao esofago de Barret, para melhor compreensao deste importante aspecto da patologia esofagica

Esophagogastric anastomosis with valvuloplasty: an experimental study.

Twenty dogs divided into two equal groups were studied by the authors in order to evaluate the functional activity and the occurrence of reflux and esophagitis after esophagogastrectomy followed by a simple esophagogastric anastomosis (group A) and associated with an anti-reflux valve mechanism (group B). The functional activity was studied by manometry at the esophagogastric junction and the occurrence of esophagitis by histologic examination of the esophagus after 25 days of histamine gastric acid stimulation. In group A, no high pressure zone between the gastric and esophageal tracings were verified. Reflux and esophagitis which, occurred in all animals, was severe in 70%. In group B, manometry demonstrated that esophagogastropexy creates a high pressure zone. At deglutition this zone showed positive deflections, corresponding to the propagation of the peristaltic wave in the segment of esophagus, encircled by the stomach. Esophagitis, which was detected in 30%, was less severe than that observed in group A.

Significado del calibre del coledoco en cirugia biliar. / The significance of the choledochus diameter in biliary surgery

Los autores estudiaron en 44 pacientes con alteraciones inflamatorias en la pared de la via biliar principal, la relacion existente entre el calibre del coledoco y la presencia en el, de coledocolitiasis, papalitis o ambas afecciones. El calibre del coledoco fue determinado durante la colangiografia operatoria y comparado con un grupo de pacientes sin afecciones en la via biliar principal. El tipo y la intensidad de la coledocitis fue determinado por el estudio histologico del material de biopsia del coledoco. Los resultados mostraron que el coledoco estaba dilatado en 88,7% de los casos. El grado de dilatacion en los pacientes con coledocolitiasis, papilitis o ambas afecciones fue semejante.No hubo relacion entre la intensidad de la coledocitis y el calibre del coledoco, pero si con el tipo de proceso inflamatorio

Significado del calibre del coledoco en cirugia biliar. / The significance of the choledochus diameter in biliary surgery

Los autores estudiaron en 44 pacientes con alteraciones inflamatorias en la pared de la via biliar principal, la relacion existente entre el calibre del coledoco y la presencia en el, de coledocolitiasis, papalitis o ambas afecciones. El calibre del coledoco fue determinado durante la colangiografia operatoria y comparado con un grupo de pacientes sin afecciones en la via biliar principal. El tipo y la intensidad de la coledocitis fue determinado por el estudio histologico del material de biopsia del coledoco. Los resultados mostraron que el coledoco estaba dilatado en 88,7% de los casos. El grado de dilatacion en los pacientes con coledocolitiasis, papilitis o ambas afecciones fue semejante.No hubo relacion entre la intensidad de la coledocitis y el calibre del coledoco, pero si con el tipo de proceso inflamatorio

Esofagite de refluxo por hernia hiatal.Estudo eletromanometrico do esfincter inferior do esofago e prova de refluxo antes e apos tratamento cirurgico. / Reflux esophagitis due to hiatal hernia.Electromanometric study of the lower esophageal sphincter and reflux test before and after surgical treatment

Foram estudados 33 pacientes com HHD que puderam ser acompanhados pelo prazo minimo de seis meses e ate oito anos apos a intervencao cirurgica pela tecnica de Lind e col. Estes pacientes foram reunidos em tres grupos de acordo com a pressao basal do esfincter inferior do esofago no pre-operatorio: Grupo I, hipotenso (media da pressao de 5,50 cm (DP : 2,89) de H20; Grupo II, normotenso (media da pressao de 13,32 cm (DP : 2,93) de H20 e Grupo III, hipertenso (media de 33,00 cm (DP : 16,28) de H20. Os resultados das medias destas pressoes no pos-operatorio, mostraramse estatisticamente significantes para os Grupos I (14,33 mais ou menos 8,93 cm de H20) e Grupo III (16,06 mais ou menos 2,66cm de H20) o mesmo nao ocorrendo com o grupo II (16,32 mais ou menos 9,02 cm de H20). Quanto a prova de refluxo acido, houve correlacao estatisticamente significativa, sendo maior a ocorrencia de RGE no periodo pre-operatorio.A prova endoscopica da continencia da cardia demonstrou a eficiencia do mecanismo valvular no pos-operatorio, na contencao do refluxo gastroesofagico, mesmo quando sao atingidos niveis pressoricos de insuflacao gastrica ate 20 mm de Hg