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Objective: The aim of this report is to describe a case of a patient with synchronous gastric tumors and demonstrate the importance of identifying this coexistence before surgery, considering that synchronicity is generally detected only after the surgery. Methods: The medical records of patients from Servidor Público Estadual Hospital of São Paulo were analyzed. Results: We identified a case of a 69-year-old male patient who presented with symptoms of dyspepsia, weight loss, and asthenia. The patient underwent serum laboratory tests, abdominal computed tomography, and upper digestive endoscopy. Analysis of the results revealed that the symptomatology was related to the association of two different gastric lesions, gastric adenocarcinoma and a nearby gastrointestinal stromal tumor (GIST), although without collision. Conclusion: The patient was submitted to a total gastrectomy with a Y-en-Roux reconstruction. Importance of the problem: Gastric cancer is the major cause of mortality of neoplastic nature, considering its high frequency and presentation of few symptoms. Although gastric adenocarcinoma and GIST are extremely different in their histopathological aspects, they can occur synchronously in the stomach. Preoperative identification of the synchronicity of these tumors is significantly important to improve surgical planning. Comments: Currently, there is a lack of a specific examination for screening GISTs, which explains the difficulty in diagnosing this tumor before the surgical procedure. In the present case, the diagnosis of adenocarcinoma was made despite the fact that two distinct gastric lesions were detected in the radiological imaging examination, and the final diagnosis of GIST was made only through anatomopathological analysis.

OBJETIVO: Analisar as características clínico-patológicas do tecido pancreático heterotópico em órgãos digestivos abdominais. MÉTODOS: Realizamos estudo retrospectivo analisando 18 portadores de pâncreas heterotópico diagnosticados histologicamente. Seus dados clínicos e histopatológicos foram revistos. O tecido pancreático heterotópico foi classificado em três modelos histológicos: tipo I constituído por três componentes do pâncreas normal (ácinos, ductos e ilhotas), tipo II com dois componentes e tipo três com somente um componente. RESULTADOS: A média de idade foi de 52,7 anos, variando de 34 a 73 anos, com nove homens e nove mulheres. Sintomas foram observados em somente quatro doentes, sendo suas lesôes diagnosticadas por gastroscopia. Os 14 restantes eram assintomáticos e suas anomalias descobertas acidentalmente. A maioria das lesões situava-se no trato superior: sete (38,9%) no estômago, seis (33,3%) no duodeno e três (16,6%) no jejuno. A heterotopia localizou-se preferencialmente na submucosa (83,3%), mas também foi observada na muscular própria e na sub-serosa. Em sete (38,9%) espécimes todos os componentes pancreáticos foram constatados (tipo I), em oito (44,4%) estavam presentes glândulas exócrinas e ductos excretores (tipo II) e em três (16,7%) somente o tecido exócrino foi observado (tipo III). CONCLUSÃO: A heterotopia pancreática é rara. Doentes com ectopia pancreática diagnosticadas pelo estudo patológico, assintomáticos ou com sintomas discretos devem permanecer em observação. As lesões detectadas acidentalmente durante procedimentos cirúrgicos necessitam ser removidas por procedimentos conservadores. OBJECTIVE: To analyze the clinical and pathological features of heterotopic pancreatic tissue in abdominal digestive organs. METHODS: We retrospectively studied 18 patients with histologically diagnosed heterotopic pancreas. Clinical and histopathologic data were reviewed. Heterotopic pancreatic tissues were classified in three histological models: Type I consists of three components of normal pancreas (acini, ducts and islets), type II with two components and type three with only one component. RESULTS: The mean age was 52.7 years, ranging from 34 to 73 years, nine of them men and nine women. Symptoms were observed in only four patients, and their lesions were diagnosed by gastroscopy. The remaining 14 were asymptomatic and their anomalies were discovered accidentally. Most of the lesions were located in the upper gastrointestinal tract: seven (38.9%) in the stomach, six (33.3%) in the duodenum and three (16.6%) in the jejunum. Heterotopia was mostly located in the submucosa (83.3%) but was also observed in the muscularis propria and in the sub-serosa. In seven specimens (38.9%) all pancreatic components were found (type I), in eight (44.4%) exocrine glands and excretory ducts were present (type II) and in three (16.7%) only exocrine tissue was observed (type III). CONCLUSION: Pancreatic heterotopia is rare. Patients with pancreatic ectopia diagnosed by pathological study, whether asymptomatic or with mild symptoms, should be observed. Lesions incidentally detected during surgeries need to be removed by conservative procedures.

OBJETIVO: Comparar duas técnicas cirúrgicas empregadas, no tratamento da doença pilonidal, a de marsupialização e da incisão e curetagem, analisando seus resultados imediatos, e tardios. MÉTODO: A casuística de 52 pacientes que apresentaram doença pilonidal sacrococcígea em suas diferentes fases, divididos em dois grupos. Grupo A, com 23 doentes submetidos à técnica de marsupialização, e grupo B, formado por 29 doentes operados pela técnica de incisão e curetagem. Todos tiveram seguimento pós-operatório de um a três anos, no período de 1981 a 1999 pelo Serviço de Gastroenterologia Cirúrgica do Hospital do Servidor Público Estadual "Francisco Morato de Oliveira" de São Paulo. A média de idade do grupo A foi de 25,39 ± 8,92 anos e a do grupo B foi de 25,52 ± 9,98 anos. A distribuição por sexo foi de 28 mulheres e 24 homens. Segundo a raça, foram 42 brancos e 10 negros. RESULTADOS: A média de tempo de duração de cirurgia, para o grupo A, submetido à marsupialização, foi de 38,91 ± 19,77 minutos, e para o grupo B, doentes submetidos à incisão e curetagem, foi de 47,34 ± 14,34 minutos. A média do tempo de internação para o grupo A foi de 3,26 dias e para o grupo B 1,28 dia. Quanto ao uso de antibiótico, em ambos grupos não foi observada diferença estatística (p>0,05). O tempo médio de cicatrização da ferida operatória nos doentes submetidos à técnica de marsupialização foi de 29,30 ±13,24 dias e para os doentes submetidos a incisão e curetagem foi de 40,76 ± 26,56 dias. A dor pós-operatória incidiu com 72,4% dos doentes do grupo B, e de 17,4% do grupo A, observando-se significância estatística (p=0,0001). O grupo de doentes submetidos à marsupialização não apresentou sangramento, enquanto no grupo da incisão e curetagem 20,7% dos enfermos tiveram sangramento (p=0,2829). A incidência de infecção pós-operatória não diferiu em ambos grupos (4,4% e 3,5%, respectivamente). O grupo B apresentou maiores índices de recidivas (17,6%) em relação ao grupo A (4,3%) com diferença estatisticamente significante (p=0,3364). CONCLUSÕES: Os procedimentos cirúrgicos empregados são de fácil execução, com períodos per-operatórios aceitáveis. A cicatrização parece ser mais eficiente nos doentes operados pela técnica de marsupialização. A técnica de incisão e curetagem apresentou maior número de complicações: dor e sangramento com maior freqüência que na técnica de marsupialização. A técnica de incisão e curetagem apresentou maior recidiva que a técnica de marsupialização. OBJECTIVE: Results of two surgical techniques for treatment of pilonidal disease, marsupialization and incision and curettage were compared. METHOD: Fifty-two patients with sacrococcygeal pilonidal disease were divided into two groups: Group A consisted of 23 patients treated with marsupialization technique, and group B was composed of 29 patients submitted to incision and curettage. Postoperative follow-up varied between one and three years, from 1981 to 1999. Mean age for group A was 25.39 ± 8.92 years and for group B 25.52 ± 9.98 years. There were 28 females and 24 males. RESULTS: The average duration of the surgery for group A was 38.91 ± 19.77 minutes and for group B 47.34 ± 14.34 minutes. The mean in-ward duration time was 3,26 days for group A and 1.28 day for group B. Regarding antibiotic use, no statistical difference was observed between groups (p>0.05). Average wound healing time associated with marsupialization was 29.30 ±13.24 days, and for incision and curettage 40.76 ± 26.56 days. Postoperative pain occurred in 72.4% of the patients in group B and 17,4% of group A (p = 0,0001). Wound bleeding was absent in patients of group A but occurred in 29.7% of patients of group B (p=0,02829). The incidence of postoperative infection did not differ between the two groups (4.4% and 3.5% respectively). Group B presented a higher reccurring rate (27.6%) compared to group A (4.3%)(p=0,03364). CONCLUSIONS: Healing appears to be more efficient in patients undergoing marsupialization technique. Incision and curettage technique presents greater number of complications, with pain and bleeding occuring more often than with the marsupialization technique. The incision and curettage technique has a higher recurring rate than the marsupialization technique.

Context Bariatric surgery has become the most effective method for producing weight loss in obese patients. The evaluation of improvement of comorbidities and changes in the quality of life are important outcome factors; however, it is necessary to investigate whether they persist over the long term. Methods A cross-sectional study was conducted on 143 obese patients from our institution from February 2007 to February 2008. These patients were divided into five independent groups, one being a control group, plus four other groups with 1, 2, 3, 4 or more years following surgical Roux-en-Y gastric bypass with a silicon ring banded. quality of life forms and anthropometric measurements were performed and its scores correlated with social factors, weight loss success, and status of obesity-related conditions. Results For the group that was 1 year postoperative, a significant percentage of excess body weight loss (EBWL%) of 81.7% was observed. The groups with 2, 3, 4 or more years of post-surgical follow-up showed a EBWL decline, but without significant difference. The main comorbidity percentages in all patients who had the surgery was as follows: 69.7% for hypertension; 88.2% for diabetes mellitus; and 27.5% for arthropathy. There was a significant decrease in the rate for diabetes resolution (P = 0.035) observed by evolutionary assessment of the comorbidity resolution. The results obtained by BAROS were good, very good, or excellent in more than 96% of patients in all evaluations that were performed. The use of the Moorehead-Ardelt Questionnaire (M/A) demonstrated improvement in the quality of life. Moreover, the quality of life, when evaluated through SF-36, also showed improvement in all related areas after 1 year; however, after 4 years, improvement remained elevated only in the areas of general state of health and functional capacity. Conclusions The Roux-en-Y gastric bypass procedure was able to achieve EBWL of 81.7% after 1 year following surgery, remaining steady with little decline after this period. Important resolution of comorbidities, such as hypertension and diabetes, was also seen. Immediate surgical outcomes assessed by SF-36 and M/A in the area of quality of life were satisfactory, but the general state of health and functional capacity areas were sustained satisfactory at a later time only.

Context Few studies have evaluated the results of different types of bariatric surgery using the Medical Outcome Study 36 - Health Survey Short-Form (SF-36) quality of life questionnaire, the Bariatric and Reporting Outcome System (BAROS) and the reviewed Moorehead-Ardelt Quality of Life II Questionnaire (M-A QoLQ II) that is part of BAROS. The Roux-en-Y gastric bypass (RYGB) is the most common morbid obesity surgery worldwide. However, there is evidence indicating that a biliopancreatic diversion with duodenal switch (DS) is more effective than RYGB in weight loss terms. Objectives To evaluate the impact of different types of bariatric surgery on quality of life, comorbidities and weight loss. Methods Two groups of patients who underwent bariatric surgery conventional Banded Roux-en-Y gastric bypass (BRYGB) or DS were evaluated through monitoring at 12 to 36 months after surgery, as well as a control group of obese patients who had not undergone surgery. The tools used for this were SF-36, BAROS and M-A QoLQ II. The DS group consisted of 17 patients and the BRYGB group consisted of 20. The control group comprised 20 independent, morbidly obese individuals. Results The mean age of the patients in the groups was 45.18 in the DS group, 49.75 in the BRYGB group and 44.25 in the control group, with no significant difference. There was no difference in the ratio of men to women in the groups. The patients that had surgery showed a significant improvement in all domains of quality of life vs the control group. Comparing the two groups that underwent surgery, the DS group achieved better quality of life results in terms of “general state of health” and “pain”, according to responses to the SF-36 tool, and in terms of “sexual interest”, according to responses to the M-A QoLQ II tool. There was no significant difference among the three groups regarding the ratio of occurrence of comorbidities. In the groups that had surgery, the resolution of comorbidities was similar. The final classification according to the BAROS Protocol was excellent for the DS group and very good for the BRYGB group, with a statistical difference in favor of the DS group (P = 0.044*). There was no difference in the percentages of excess weight loss between the DS group (82.1%) and the BRYGB group (89.4%) (P = 0.376). Conclusions A comparison of the performance of the groups, which were monitored from 12 to 36 months after surgery, showed that the two types of surgery are effective to improve quality of life, comorbidities and weight loss. The DS surgery produced better results in the quality of life evaluations regarding 2 of 8 domains according to the SF-36, and “sexual interest” according to the M-A QoLQ II. In the groups that had surgery, the patients showed high rates of comorbidity resolution. Weight loss was similar for the two surgical groups. Contexto Poucos estudos avaliaram os resultados de diferentes cirurgias bariátricas utilizando o questionário de qualidade de vida Medical Outcome Study 36 - Item Health Survey Short-Form (SF - 36), o Bariatric and Reporting Outcome System (BAROS) e o Moorehead-Ardelt Quality of Life II (M-A QoLQ II) revisado, que compõem o BAROS. A derivação gástrica em Y de Roux é a operação mais realizada em todo o mundo para tratamento da obesidade mórbida. Há evidencias sugerindo maior efetividade da operação derivação biliopancreática tipo “duodenal switch” (DS) em relação a derivação gástrica em Y de Roux quanto à perda de peso Objetivos Avaliar o impacto de diferentes intervenções cirúrgicas na qualidade de vida, comorbidades e perda de peso. Métodos Foram avaliados dois grupos de doentes submetidos à cirurgia bariátrica de derivação gástrica em Y-de-Roux com anel (BRYGB) ou “duodenal switch” após seguimento de 12 a 36 meses e, um grupo controle de doentes obesos não operados, utilizando o SF-36, o BAROS e o M-A QoLQ II. O grupo DS foi constituído por 17 doentes e, o BRYGB convencional, por 20. O grupo controle foi formado por 20 doentes obesos mórbidos independentes. Resultados A média de idade dos doentes nos grupos foi respectivamente 45,18 anos no grupo DS, 49,75 anos no grupo BRYGB e, 44,25 anos no grupo controle, sem diferença significante. Não foi observada diferença entre as proporções de sexo nos grupos. O grupo de pacientes operados apresentou melhora significante em todos os domínios de qualidade de vida, em relação ao grupo controle. Na comparação entre os grupos cirúrgicos, o grupo DS apresentou resultados de qualidade de vida melhores nos domínios “estado geral da saúde” e “dor” do SF-36 e na questão “interesse sexual” do M-A QoLQ II. Não houve diferença significante entre os três grupos nas proporções de ocorrências de comorbidades. Nos grupos de pacientes operados a resolução das comorbidades foi semelhante. A classificação final do Protocolo BAROS no grupo DS foi excelente e no grupo BRYGB foi muito bom, com diferença estatística a favor do grupo DS (P = 0,044*). Não houve diferença nos porcentuais de perda de excesso de peso entre os grupos DS (82,1%) e BRYGB (89,4%) (P = 0,376). Conclusões A comparação dos grupos no seguimento entre 12 e 36 meses demonstrou que as duas operações são eficazes para a melhora da qualidade de vida, das comorbidades e da perda de peso. A operação DS apresentou melhores resultados nas avaliações de qualidade de vida em 2 dos 8 domínios do SF-36, e “interesse sexual” do M-A QoLQ II. Nos grupos operados, os pacientes apresentaram altas taxas de resolução de comorbidades. A perda de peso foi semelhante em ambos os grupos cirúrgicos.

Intravenous lipid emulsions are used as energy and essential fatty acids sources. There are controversial reports postulating in vitro and in vivo inhibitory effects of long-chain triglycerides (LCT) upon the blood polymorphonuclear leukocytes (PMNL) functions. In the present study the in vivo and in vitro effects of LCT and a physical mixture of medium- and long-chain triglycerides (MCT/LCT) emulsions were investigated on select PMNL functions, i.e., chemotaxis, phagocytosis, and bacterial killing. Blood from 20 rats was incubated with LCT, MCT, MCT/LCT, and saline, respectively. MCT-containing emulsions exhibited an inhibitory effect on all PMNL functions investigated, whereas LCT exerted an effect on the phagocytic index only. The administration of a parenteral supply of LCT, MCT/LCT, and saline for 30 h followed by saline infusion for 14 h in discontinuous mode did not influence any of the investigated PMNL functions. Similarly, continuous infusion over 44 h at increasing infusion rates up to 1.5 mL/h did not affect the PMNL functions. The obvious difference between in vitro and in vivo response of the PMNL model emphasizes the necessity for continuous monitoring of in vivo conditions. Appropriate interpretation of the data requires continuous circumspection and consideration of trials in a clinical setting.

To analyze the clinical and pathological features of heterotopic pancreatic tissue in abdominal digestive organs.We retrospectively studied 18 patients with histologically diagnosed heterotopic pancreas. Clinical and histopathologic data were reviewed. Heterotopic pancreatic tissues were classified in three histological models: Type I consists of three components of normal pancreas (acini, ducts and islets), type II with two components and type three with only one component.The mean age was 52.7 years, ranging from 34 to 73 years, nine of them men and nine women. Symptoms were observed in only four patients, and their lesions were diagnosed by gastroscopy. The remaining 14 were asymptomatic and their anomalies were discovered accidentally. Most of the lesions were located in the upper gastrointestinal tract: seven (38.9%) in the stomach, six (33.3%) in the duodenum and three (16.6%) in the jejunum. Heterotopia was mostly located in the submucosa (83.3%) but was also observed in the muscularis propria and in the sub-serosa. In seven specimens (38.9%) all pancreatic components were found (type I), in eight (44.4%) exocrine glands and excretory ducts were present (type II) and in three (16.7%) only exocrine tissue was observed (type III).Pancreatic heterotopia is rare. Patients with pancreatic ectopia diagnosed by pathological study, whether asymptomatic or with mild symptoms, should be observed. Lesions incidentally detected during surgeries need to be removed by conservative procedures.

São apresentados 18 casos de neoplasias primárias do duodeno, salientando-se sua raridade e as dificuldades diagnósticas, a despeito dos modernos recursos endoscópicos e de identificação por imagem. A literatura revela que de 1% a 10% de todos os tumores do aparelho digestório se situam no intestino delgado. A localização duodenal é, por isso, muito pouco freqüente, possui sintomatologia indefinida e implica conduta terapêutica mais complexa do que quando o tumor se situa em outros segmentos do intestino delgado. Os sintomas mais comuns são dor, náusea, vômito e hemorragia. A presente casuística consiste de 11 neoplasias malignas e sete benignas. Entre as primeiras o adenocarcinoma é o mais freqüente, sendo os lipomas os mais comuns dos neoplasmas benignos. Enquanto nestes a exérese local representa a conduta mais adequada, a duodenopancreatectomia cefálica foi a cirurgia de escolha nos tumores malignos da segunda porção duodenal, exibindo bons resultados. As lesões malignas da terceira porção e principalmente da quarta porção do duodeno foram tratadas pela ressecção duodenojejunal, também com resultados satisfatórios. Eighteen primary duodenal tumors, including 11 malignant and 8 benign, are presented, stressing their poorly defined natural history and rare frequency. The most common histological diagnosis was adenocarcinoma. There were 6 adenocarcinomas, 2 carcinoids, 1 linfoma, 1 anaplastic and 1 neuroectodermic carcinoma. Benign lesions were occasionally found during a gastroduodenal or a biliary surgery (n = 4) and during the autopsies (n = 3). They consisted of lipomas (n = 4), adenomatous polyps (n = 2) and leiomyoma (n = 1). Concerning the malignant lesions, 6 pancreaticoduodenectomies, 3 duodenojejunal segmentary resection and one paliation consisting of gastrojejunostomy and biopsy were performed. One carcinoid lesion was found at the duodenal bulb during a gastroduodenectomy for a gastric ulcer. Pancreaticoduodenectomy can be done with acceptable risk and it seems that patients with duodenal adenocarcinoma are more likely to survive longer after radical surgery than those with cancer of the head of pancreas. Every patient of this series treated by pancreaticoduodenectomy or duodenojejunal segmentary resection had an uneventful recovery and the follow-up ranged from 16 months to 7 years. As for the duodenal carcinoids, local resection is usually followed by recurrence, so an agressive surgical management is the best approach. Benign tumors must be treated by local excision when disclosed.