Atlas Assimilation Patterns in Different Types of Adult Craniocervical Junction Malformations.

STUDY DESIGN: This is a cross-sectional analysis of resonance magnetic images of 111 patients with craniocervical malformations and those of normal subjects. OBJECTIVE: To test the hypothesis that atlas assimilation is associated with basilar invagination (BI) and atlas's anterior arch assimilation is associated with craniocervical instability and type I BI. SUMMARY OF BACKGROUND DATA: Atlas assimilation is the most common malformation in the craniocervical junction. This condition has been associated with craniocervical instability and BI in isolated cases. METHODS: We evaluated midline Magnetic Resonance Images (MRIs) (and/or CT scans) from patients with craniocervical junction malformation and normal subjects. The patients were separated into 3 groups: Chiari type I malformation, BI type I, and type II. The atlas assimilations were classified according to their embryological origins as follows: posterior, anterior, and both arches assimilation. RESULTS: We studied the craniometric values of 111 subjects, 78 with craniocervical junction malformation and 33 without malformations. Of the 78 malformations, 51 patients had Chiari type I and 27 had BI, of whom 10 presented with type I and 17 with type II BI. In the Chiari group, 41 showed no assimilation of the atlas. In the type I BI group, all patients presented with anterior arch assimilation, either in isolation or associated with assimilation of the posterior arch. 63% of the patients with type II BI presented with posterior arch assimilation, either in isolation or associated with anterior arch assimilation. In the control group, no patients had atlas assimilation. CONCLUSION: Anterior atlas assimilation leads to type I BI. Posterior atlas assimilation more frequently leads to type II BI. Separation in terms of anterior versus posterior atlas assimilation reflects a more accurate understanding of the clinical and embryological differences in craniocervical junction malformations. LEVEL OF EVIDENCE: N/A.

Management of choledochal cyst / Tratamento do cisto de colédoco

BACKGROUND: Choledochal cysts are rare diseases in adults. The risk of malignant transformation is well documented to be age-related and early complete cyst excision is currently advocated. Type IVa cyst management is more controversial. Extensive intrahepatic involvement of the biliary system may preclude complete excision. AIM: The aim of this study was to present a case of type IVa choledochal cyst in a young female patient. CASE REPORT: An 18-year-old female, complaining of right upper quadrant pain, nausea, vomiting, fever, and jaundice was admitted. The diagnosis of type IVa choledochal cyst was made by computerized tomography. The patient was underwent cholecystectomy, excision of the anterior wall of the cyst, and Roux-en-Y hepaticojejunostomy. No postoperative complication was noted and the patient was discharged five days after operation. CONCLUSION: Total cyst excision is the ideal treatment of choledochal cysts in adults. However, in IVa type, due to the extensive intrahepatic involvement of the biliary system, the anatomy of the cyst, and the surgeon's judgment will determine the surgical approach taken for the patient.

RACIONAL: A doença de cistos de colédoco em adultos é rara. O risco de transformação maligna é bem documentado, sendo relacionado a idade, além da completa excisão do cisto ser aconselhada. O manuseio e gestão do cisto tipo IVa gera maior controvérsia. O envolvimento intra-hepático extensivo do sistema biliar pode prevenir a sua completa excisão. OBJETIVOS: Relatar o caso de um cisto de colédoco do tipo IVa em paciente feminina. RELATO DE CASO: Paciente feminina, 18 anos de idade, foi admitida com queixa de dor no quadrante superior direito, náusea, vômitos, febre e icterícia. O diagnóstico de cisto de colédoco do tipo IVa foi realizado através de tomografia computadorizada. A paciente foi submetida à colecistectomia, excisão da parede anterior do cisto e hepatojejunostomia em Y-de-Roux. Nenhuma complicação pós-operatória ocorreu e a paciente recebeu alta após 5 dias da operação. CONCLUSÃO: A excisão total do cisto é o tratamento ideal para cistos de colédoco em adultos. Entretanto, no cisto do tipo IVa, devido ao seu envolvimento intra-hepático extensivo do sistema biliar, sua anatomia e o discernimento do cirurgião determinarão a medida a ser tomada.

Duodenopancreatectomias: análise de 39 pacientes / Pancreaticoduodenectomies: analysis of 39 patients

OBJETIVO: Pretendemos neste estudo analisar 39 pacientes submetidos à duodenopancreatectomia. MÉTODO: No período de julho de 1998 a março de 2004, trinta e nove pacientes foram submetidos a duodenopancreatectomia no Hospital Universitário da Universidade Federal do Maranhão. Foram analisados os dados epidemiológicos, o quadro clínico, os métodos radiológicos, as indicações da operação e as complicações encontradas . RESULTADOS: Havia 22 pacientes do sexo masculino (56,4 por cento) e 17 pacientes do sexo feminino (43,6 por cento) com média de idade de 54,9 anos (variação de 21-82 anos). O exame radiológico mais utilizado foi a tomografia computadorizada. O diagnóstico histológico definitivo revelou adenocarcinoma periampolar em 35 pacientes (89,7 por cento), pancreatite crônica (três pacientes - 7,7 por cento) e adenocarcinoma colo-retal (um paciente - 2,6 por cento). O adenocarcinoma periampolar mais freqüente foi o carcinoma ductal do pâncreas (27 pacientes - 69,2 por cento), seguido por carcinoma de papila de Vater ( cinco pacientes - 12,8 por cento), adenocarcinoma duodenal (dois pacientes - 5,1 por cento) e carcinoma de via biliar distal (um paciente - 2,6 por cento). As complicações pulmonares foram as mais freqüentes sendo encontradas em cinco pacientes (12,8 por cento), a sepse peritoneal em quatro pacientes (10,2 por cento), fístula pancreática em três pacientes (7,6 por cento) e a hemorragia0 intra-abdominal em três pacientes (7,6 por cento). A mortalidade intra-hospitalar em 30 dias foi 10,2 por cento (quatro pacientes). CONCLUSÃO: A duodenopancreatectomia ainda está associada a morbidade considerável. Entretanto com uma seleção adequada destes pacientes este procedimento pode ser realizado de forma segura com melhores resultados.

BACKGROUND: The aim of this study is to analyze 39 patients underwent Whipple's operation. METHOD: In the period from July 1998 to March 2004, thirty-nine patients underwent pancreaticoduodenectomy at University Hospital, Federal University of Maranhão. The diagnosis was made on the basis of computed tomography scan, ultrasound scan, Magnetic Resonance Imaging, and Endoscopic Retrograde Cholangiopancreatography. RESULTS: There were 22 male (56.4 percent) and 17 female (43.6 percent) and the mean age was 54.9 years (range 21-82 years).Definitive histology was available and showed periampullary adenocarcinoma in 35 patients (89.7 percent), chronic pancreatitis (3 patients - 7.7 percent), and colon adenocarcinoma (1 patient - 2.6 percent). The most common periampullary adenocarcinoma was pancreatic adenocarcinoma (27 patients - 69.2 percent), followed by ampullary (5 patients - 12.8 percent), duodenal carcinoma(2 patients - 5.1 percent), and distal bile duct (1 patient - 2.6 percent). The most common category of complication was pulmonary in five patients (12.8 percent), followed by intra-abdominal sepsis in four patients (10.2 percent), pancreatic anastomotic fistula in three patients (7.6 percent), and bleeding in three patients (7.6 percent). Overall 30-day in-hospital mortality in this series was 10.2 percent (four patients). CONCLUSION: Pancreaticoduodenectomy continues to be associated with considerable morbidity. However, with careful patient selection, this procedure can be performed safely and with better outcome.

Hepatectomia central / Mesohepatectomy

A ressecção hepática é o tratamento apropriado para uma variedade de lesões benignas e malignas, primárias e secundárias. Quando estas lesões são localizadas na região central o problema persiste. A hepatectomia central é uma forma de minimizar o volume de fígado ressecado e evitar a insuficiência hepática pós-operatória. Objetivo - o presente estudo é registrar um caso de hepatectomia central / Hepatic resection is appropriate treatment for a variety of benign and primary or secondary malignant lesions. Centrally located lesions remains problematic. Mesohepatectomy is one way to minimize the volume of liver resected and in preventing postoperative liver failure. Objective - the aim of the present study is to report a case of mesohepatectomy...