[Quality control of vagotomy in duodenal ulcer perforation]. / Controle de qualidade da vagotomia na perfuração de úlcera duodenal.

The efficacy of truncal vagotomy combined with pyloroplasty has been studied in 56 patients, divided into the following groups: Group I-29 patients submitted to bilateral truncal vagotomy (BTV) and pyloroplasty, as the method of treatment to solve the problem of perforated duodenal ulcer (initial and retrospective phase of study). Group II-With 11 patients, who underwent the same operation as those in Group I but with the surgeon's knowledge of the results of phase I and also awareness of the laboratory control of its surgery (prospective phase). Group III-A control Group of 16 patients, with chronic duodenal ulcer submitted to a routine proximal gastric vagotomy (superselective or hyperselective vagotomy). All of the patients were clinically evaluated and all of them have done acid secretion studies (Kay and Sham-Feeding test). Basal acid output (BAO), maximum acid output after Sham-Feeding (PAOsf), and pentagastrine (PAOpg), were determined in order to control the efficacy of vagotomy. In group III, results were compared with those obtained pre-operatively. In Group I, 48.27% of patients had a PAOsf higher than 4 mEq/hour-value which has been considered the maximum level of normality after complete BTV without gastric resection. In Group II, the number of patients with incomplete vagotomy decrease to 18.18%. In Group III, all the patients had a PAOsf lower than 4 mEq/hour and 83.81% of acidity reduction after Sham-Feeding test, in comparision with the pre-operative values.(ABSTRACT TRUNCATED AT 250 WORDS)

[The ethics of organ donation for transplantation]. / Consideraoes sobre a ética da doação de órgãos para transplantações.

The new law 12/93, which regulates organ donation for transplantation in Portugal, is reviewed. The author emphasizes the importance of some legal improvements to allow a better fulfillment of the first principles of ethics that will rule the conflicts of interest between living and dead donors and recipients. Criticism is made of the interference that the Ministry of Health will have in the decision of doctors' and Medical Centres' competence. The importance given to economic reasons which stimulate political promotion and minimise ethical and professional reasons would become future factors of obstruction and backwardness.

[Surgical therapy of peptic stenosis of the esophagus in adults]. / Terapêutica cirúrgica da estenose péptica do esófago no adulto.

One hundred and one patients with reflux esophagitis and strictures, submitted to different kinds of surgical solutions over the last 16 years, were revised. Seventy seven patients had dilatable stricture and the lower esophageal sphincter mechanism could be brought intra-abdominally in 70. In 36 there was radiographic evidence of hiatal hernia and 8 had a Barrett esophagus. The surgical technique employed in these cases was transgastric dilatation of the stricture, and Nissen fundoplication in 63 and partial fundoplication in 13 patients with peptic stricture post BI or BII6, gastroenterostomy or pyloromyotomy and vagotomy and post Heller myotomy. The post-operative mortality was 2.6% (2 in 77 patients) and morbidity 14.3%. Results after 5 years of follow-up have been classified as good to excellent in 88.3%. Six out of 9 remaining patients needed more than 3 dilatations in the first year after surgery and 3 of these were reoperated. Twenty four patients had a fixed stricture: In 22 of them, the area of esophagogastric stenosis was resected with replacement of the esophagus by colon interposition in 6, jejunum in 14, and a gastric tube with cervical anastomosis in 2. In two patients of advanced age and with respiratory problems a retrosternal by-pass with colon was performed. In this group the post-operative mortality was 12.5% (3 in 24 patients) and the morbidity 25%. The most common problems after one year of surgery were diarrhea (4 patients) and gastric fullness in 2. Eleven patients remained asymptomatic after 5 years (9 with jejunum interposition and 3 with colon) and 3 with jejunum were alive after 10 years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Roux-en-Y gastrectomy. A 12 years' experience]. / Gastrectomia de tipo Roux-em-Y. Uma experiência de 12 anos.

A review of 161 patients who underwent Roux-en-Y biliary diversion and truncal vagotomy from 1978 to 1989 is performed under the double perspective: clinical and functional (using radionuclide semi-solid and liquid gastric emptying (GE) studies). In 46 patients this solution was adopted to treat different kinds of post-gastrectomy syndromes and in 115 to solve the esophageal-duodeno-gastric peptic disease. Some technical details are considered very important to prevent the nominated post Roux-en-Y Syndrome in relationship with the gastroparesis and gastric retention. The overall operative mortality was 2.5%. Five patients were reoperated: two, to complete vagotomy; 2, to solve gastric retention and one with sub-occlusion due to jejunal stricture. Forty one patients with 7.4 +/- 1.3 years after surgery were graded Visick I or II in 82.9% of the cases and 17.1% Visick III or IV. Gastric emptying studies demonstrated that the problems of gastric fullness detected in the immediate post operative period are quite similar to those observed after other kinds of sub-total gastrectomies. After 6 months, the gastric emptying change to a more rapid pattern in the large majority of patients. In the late post operative period is quite common to have no agreement between gastroparesis complains and the objective measurements of the GE, in symptomatic patients. Roux-en-Y gastrectomy solve the problems of post gastrectomy syndromes in 80% of the cases and in our experience, is a method that can be used with advantage to treat the ulcerative peptic disease resistant to the medical treatment in patients with less than 50 years.

[Total gastrectomy with creation of a new stomach using the jejunum. A retrospective study of 120 patients]. / Gastrectomia total com construção de um neo estômago com jejuno. Estudo retrospectivo de 120 doentes.

Results obtained in 120 patients with gastric carcinoma, and submitted between 1982 and 1989, to a total gastrectomy and a new technique of reconstruction with jejunum, are analyzed retrospectively. This technique associates, a jejunoplication around the terminal esophagus with the purpose to eliminate the entero-esophageal reflux and the risk of dehiscence, and a double jejuno-jejunostomy with the target to delay the emptying of foods and to increase the reservoir function of the neo-stomach. In 63 of these patients a lymphadenectomy type R2-R3 has been held and in the remainder a type R1 lymph node dissection. Pre-operative chemotherapy was done when there was significant weight loss or proved obstruction of the cardia or pylorus by a radioisotopic method. Post-operative chemotherapy was continued immediately after operation in all the patients with pre-operative improvement. Operative mortality until the 60th day of Hospital stay was 5.8% and was mainly related with the advanced age of the patients and the spread and localization of the tumor. Operative morbidity was also more marked in tumors spreading to the cardia. The five years actuarial survival rate was 17.2% to the stage III and IV and 38.8% to the stage I and II. The quality of life of the patients has been favored by the kind of gastric reconstruction that has been used: Jejunoplication reduce the entero-esophageal reflux to nearly 20% and the double enterostomy, specially if the duodenal transit is maintained, induce a more slow post-operative emptying than other kinds of reconstruction. This fact is related with a more physiologic absorption of glucose and to a more favorable nutritional condition.

[Preservation of the liver using a new solution of phosphate-buffered saccharose]. / Preservação do fígado com uma nova solução de sacarose tamponada com fosfato.

The efficacy of the new phosphate-buffered sucrose solution (PBS), was compared with the conventional Euro-Collins (EC) and the lactated Ringer solution (LR), in its capacity to preserve the canine liver in cold storage. Three groups of 6 canine livers, each group in one of those solutions, were put in cold storage for 24 h at 4 degrees centigrade. At the end of this period the effect of warm hepatic reperfusion was studied in relationship with the following parameters: weight of the liver, bile excretion, hepatic biopsy, Na, K, Ca, P and some tests used to evaluate the hepatic function. The results obtained confirm, that PBS has an important impermeant effect over the hepatocyte, simulating that described recently by Lam et al to the kidney. Contrary to the EC and LR, the PBS inhibits hypothermic cell swelling, is more effective in the preservation of the liver histology, and has an opposed effect to the weight gain tendency induced by cold storage. During the period of warm reperfusion, high volumes of bile excretion and lesser levels of K depletion were observed in the PBS model. PBS is easy to prepare, and it is not expensive. For these reasons PBS could be an advantageous substitute of the EC in liver preservation.

[A comparative study of gallbladder function using echography and HIDA-CCK]. / Estudo comparativo do funcionamento da vesícula biliar com ecografia e HIDA-CCK.

This paper compares two methods of evaluating gall-bladder function after stimulation with cholecystokinin (CCK); One, the echographic method, permits the gall-bladder contraction study by determining variations in face area of the organ. The other, the scintigraphic method (HIDA-CCK test), studies of the gall-bladder emptying registering the decreases of activity by external counts. Out of 20 studies performed: 8 cases presented a contractile response and normal emptying; 7 had an abnormality late initial response (Ti) and contraction and emptying (defined by T1/2) slower than normal. In the 5 patients the gall-bladder traced with HIDA did not respond to CCK. Within this group, one patient had an incomplete painful contraction, evaluation by echography. The onset of pain or sub-costal discomfort was a variable finding within the different study groups. The linear coefficient correlation for the normal group and for the patients with late response was 0.8255 (x = 2.216 gamma-4.59). Based on these data and taking into account cheaper cost, patient comfort, and greater availability of equipment, the echographic method for studying gall-bladder contraction after administration of CCK, can be used instead of the HIDA-CCK procedure.

[Current possibilities of surgical treatment of hepatocellular carcinoma. Apropos of a clinical case]. / Possibilidades actuais da terapêutica cirúrgica no carcinoma hepatocellular. A propósito de um caso clínico.

The recent improvement in surgical of therapy of carriers of hepatocellular carcinoma is due to both an early diagnosis of the illness and in the evaluation of set of prognostic and resectability factors. On describing a clinical case of a hepatocellular carcinoma localized on the left lobe of a healthy liver, the importance of the analysis of those factors of prognostic and resectable evaluation is shown up, compared to those in our case. Finally, a methodology is proposed for a diagnostic tracing in accordance with the present possibilities of curable and palliative therapeutics.