Unsuspected colon adenocarcinoma revealed after laparoscopic cholecystectomy

A particularly rapid and fatal outcome has been noted in cases of malignant soft-tissue metastases occurring after cancer surgery. Abdominal wall metastases occurring in scars after laparotomy for cancer resection show a similar poor outcome. On the other hand, neoplasm seeding at trocar sites after laparoscopy has been reported with an increasing frequency. A case is presented of a 68-years-old woman with metastatic seeding of non-diagnosed colon cancer at the umbilical trocar site used for a laparoscopic cholecystectomy. The gallbladder was extracted through the umbilical incision. Pathological examination confirmed chronic cholecystitis. Eight months latter, the patient was seen with a tender umbilical mass protruded through a 4,5 cm the umbilical incision site. Biopsies of this tissue were taken and histopathological examination showed metastatic adenocarcinoma, probably of a gastrointestinal origin. A colonoscopy performed at the same time revealed a 2-cm lesion at the hepatic flexur which was shown to be a differentiated adenocarcinoma. An 8.0 x 6.0 x 6.0-cm pelvic mass without signs of liver metastases was identified by computerised tomography. Diagnostic laparoscopy showed a diffuse peritoneal carcinomatosis. The pelvis could not be approached, except for simple biopsy, and no surgical procedure was performed. It is presumed that the primary colon cancer existed prior to cholecystectomy. Laparoscopy is the procedure of choice to perform cholecystectomy and fundoplication. It has also been increasingly used to diagnose, resect and perform the staging of malignant tumours. As in any relatively new technique, questions arising about its safety and risk of complications must be extensively studied. Many questions about the specific features of laparoscopy promoting cancer growth remain unanswered.UNIFESP-EPM Departamento de CirurgiaHospital do Servidor Público Estadual de São PauloUNIFESP, EPM, Depto. de CirurgiaSciEL

One layer sutures of digestive tract knotted in the lumen, in dogs: perforating stitch versus serosubmucosal suture

OBJECTIVE: To compare hand sewn digestive tract single layer anastomosis with knots tied in the lumen: total stitches versus serosubmucosal. METHODS: Six mongrel dogs were submitted to laparotomy, each one with two transversal jejunum sections, 30 and 70 cm far from Treizt angle and suture, serosubmucosal and total stitches, both with knots tied in the lumen, over the mucosa, at the posterior wall. After slaughter (7th post-operative day) was evaluated the peritoneal adhesions at posterior wall. The macro and microscopic features was observed. Wilcox on rank sum test was applied for the histhometry. RESULTS: More profuse adhesions with the serosubmucosal stitches tied in the lumen with adherence tissue over the suture line, avoiding the serosa, within or without healing deformation of the suture lines, doing an anastomosis´angle. There was good serosa reconstitution with total stitches. The epithelium was perfectly reconstituted at serosubmucosa, but not at total stitches, where was residual focus of acute inflammation. The reline and regeneration of wall components (except the serosa, whose regeneration was impaired by peritoneal adherences) were better with serosubmucosal then total stitches. The muscularis never regeneration in anyone suture. The polimorphonuclear cells, macrophages, fibroblasts, and collagen fibers was more numerous (statistical significance) at total stitches. COCLUSION: Total stitches with knots tied in the lumen, at posterior wall, over the mucosa are safe full, despite of major inflammation. Serosubmucosal with knots tied in the lumen, at posterior wall, over the mucosa, allows peritoneal adherences formation, and should be avoided.OBJETIVO: Comparar a anastomose do tubo digestivo em plano único com nós atados no lume por sutura com pontos totais versus pontos extramucosos. MÉTODOS: Foram operados seis cães, com realização de duas secções transversas do jejuno a 30 cm e a 70 cm da flexura duodenojejunal e sutura, na face posterior com pontos extramucosos atados sobre a submucosa, e na face anterior com pontos totais atados sobre a mucosa. No 7º PO foram avaliadas, na face posterior, as aderências na linha de sutura e feitos exames macroscópico e microscópico. RESULTADOS: As aderências peritoneais foram mais profusas nas suturas extramucosas com tecido aderencial sobre a linha de sutura, sem reconstituição da serosa, ou com a deformidade cicatricial das serosas dos cotos angulando a anastomose. A serosa teve boa reconstituição nas suturas totais. O epitélio mucoso reconstituiu-se perfeitamente nas extramucosas, mas não nas totais. Nas suturas totais houve focos residuais de inflamação aguda.O realinhamento, a reestruturação e a regeneração das camadas (exceto a serosa, cuja regeneração foi prejudicada por aderências) foi melhor na sutura extramucosa que na total. A muscular da mucosa não se regenerou em nenhuma anastomose. Os polimorfonucleares, os macrófagos, os fibroblastos e as fibras colágenas foram mais numerosos (significância estatística) na sutura total. CONCLUSÃO: As suturas totais da parede posterior da anastomose com nós atados no lume, sobre a mucosa, são seguras, apesar da inflamação maior. A sutura extramucosa da parede posterior, com nós atados no lume, sobre a submucosa, propicia a formação de aderências peritoneais, devendo ser evitada.Universidade Federal de São Paulo (UNIFESP)UNIFESPHospital do Servidor Público do Estado de São PauloUNIFESPSciEL

Evaluation of the position of veress' needle tip during establishment of pneumoperitoneum by closed technique, in pigs

BACKGROUND: To establish reliable evidence regarding the adequate positioning of the tip of a Veress needle in the interior of the peritoneal sac during the establishment of the pneumoperitoneum by the closed technique. METHODS: In 11 pigs, the needle was introduced in the peritoneal sac through the left hipocondrium. Tests of positioning of the tip of the instrument were carried out. Gas (CO2) was injected, and pressures, flows and volumes were registered periodically. The correct intraperitoneal position of the needle was confirmed and, subsequently, removed, being reintroduced in the right hipocondrium and placed under direct vision in the pre-peritoneal space. The same parameters were surveyed. RESULTS: The test of the draining was always positive in the peritoneum. Resistance to the infusion of serum in the peritoneal sac was not observed, but resistance was detected on 45.5% of cases in the pre-peritoneal space. Some serum was recouped in 63.5% of cases in the peritoneal sac and in 54.5% in the pre-peritoneal space. The dripping flowed freely in 66.6% of cases in the peritoneal sac and in 45.5% in the pre-peritoneal space. In the peritoneal sac, = 5mmHg initial pressure increased gradually during 120 seconds until reaching 15 mmHg. In the pre-peritoneal space, the initial pressure was of 15mmHg and oscillated between 12 and 15mmHg. The volume of gas injected was of 1500 ml in the peritoneal sac and of 100 ml in the pre-peritoneal space. CONCLUSION: Initial pressure of ±5mmHg is indicative of the tip of the needle being placed in the peritoneal sac, inside of which there should fit ten times more gas than in the pre-peritoneal space. When the tip of the Veress needle is placed in the interior of the peritoneal sac, the increase of intraperitoneal pressures and volumes can be predicted by statistics.OBJETIVO: Estabelecer parâmetros fidedignos do posicionamento adequado da agulha de Veress na cavidade peritoneal durante o estabelecimento do pneumoperitônio pela técnica fechada. MÉTODO: Em 11 porcos a agulha foi introduzida na cavidade peritoneal através do hipocôndrio esquerdo. Provas de posicionamento da ponta do instrumento foram efetuadas. Insuflou-se CO2 e registraram-se periodicamente pressões, fluxos e volumes. A posição intraperitoneal da agulha foi confirmada e esta foi retirada, sendo re-introduzida no hipocôndrio direito e posicionada sob visão direta no espaço pré-peritoneal. Os mesmos parâmetros foram aferidos. RESULTADOS: A prova do escoamento foi sempre positiva no peritônio. Não se encontrou resistência à introdução de soro no peritônio em nenhum caso, mas sim em 45,5% dos casos no pré-peritônio. Soro algum foi recuperado em 63,5% no peritônio e em 54,5% no pré-peritônio. O gotejamento fluiu livremente em 66,6% das vezes no peritônio e em 45,5% dos casos no préperitônio. No peritônio, pressões iniciais de 5,20 mmHg aumentaram progressivamente durante 123 segundos até atingir 15 mmHg. No pré-peritônio a pressão inicial foi de 15,60 mmHg e oscilou entre 12 e 15,60 mmHg. O volume de gás injetado no peritônio foi de 1500 ml e de 100 ml no pré-peritônio. CONCLUSÕES: Aspiração e observação do escoamento e do gotejamento são importantes; recuperar ou não o soro é inconclusivo. Pressão inicial menor ou igual a 5 mmHg é indicativo da ponta da agulha no peritônio, onde devem caber dez vezes mais gás que no pré-peritônio. No peritônio os aumentos das pressões e dos volumes pode ser previstos mediante estatísticas.UNIFESP Departamento de CirurgiaUNIFESP Setor de VideocirurgiaSociedade Brasileira de Cirurgia LaparoscópicaUniversidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM)Hospital do Servidor Público do Estado de São PauloUNIFESPUNIFESP, Depto. de CirurgiaUNIFESP, Setor de VideocirurgiaUNIFESP, EPMUNIFESPSciEL

Wound healing of laparoscopic Heller's myotomy with and without an added dor's fundoplication, in pigs

BACKGROUND: It has been argued that a Dor's fundoplication following myotomy is useful to prevent leakage due to overlooked iatrogenic perforations of esophagus and it is able to stop sphincter reconstruction, avoiding recurrent achalasia. Another strain of thought is that anterior fundoplication causes significant local distortion by fibrosis because the gastric patch impairs mesotelial epithelization by covering the myotomy and that iatrogenic perforations are easily diagnosed by laparoscopic magnification. The purpose of this research is to compare the wound healing of the laparoscopic esophageal myotomy with and without a gastric patch. METHODS: Eighteen male pigs were distributed into three groups of six. Esophageal myotomy was performed in group A. A gastric patch was associated to group B. Myotomy was not performed in group C. On the 21st postoperative day, lumen molding was accomplished to determine the index of stenosis (IS) at the area of myotomy (AM) and at the oesophagogastric junction (OJ) RESULTS: Longer operative duration (t Student) in group B (93. 6) than in group A (45). At AM, IS was negative (lumen increased) and equivalent in both groups (Mann-Withney): -11.1% in group A and -12.7% in group B. IS at OJ was always higher than IS at AM (Wilcoxon): 18% versus -11.1% in group A and 37.7% versus -12.7% in group B. IS at OJ in group B (37.7%) was predominant among all groups (Kruskal-Wallis): group A = 18%; group C = 15.5%. Mesotelial epithelium was observed in group A. Inflammatory reaction was greater in group B (leucocytes: 22 versus 8.6; fibrosis: 25.5 fibers versus 15.6; and granulation tissue: 18.7 vessels versus 9.7) than in group A. CONCLUSION: Esophageal myotomy followed by Dor's fundoplication does not heal adequately and also results in lumen stricture at the oesophagogastric transition. Myotomy without gastric patch is faster and causes less inflammation.OBJETIVO: Comparar a cicatrização da miotomia esofagiana laparoscópica associada ou não à fundocardioplastia de Dor. MÉTODO: Foram utilizados 18 porcos, em três grupos de seis animais. No grupo A foi realizada miotomia esofagiana. No grupo B associou-se plicatura gástrica à miotomia. O grupo C foi sem miotomia. No 21º dia pós-operatório houve moldagem do lume para obter índices de estenose (IE) na região da miotomia (RM) e na transição esôfago-gástrica (I'E'). Foram também estudados aspectos macro e microscópicos. RESULTADOS: Duração maior (t de Student) no grupo B (93,6 minutos) que no A (45 minutos). Considerando- se o IE dos grupos A e B, não houve estenose e eles se equivaleram - Mann-Withney (-11.1% no grupo A e -12.7% no grupo B). O I'E' foi sempre maior que o IE - Wilcoxon (18% versus -11,1% no grupo A e 37,7 % versus -12.7% no grupo B). O I'E' do grupo B (37,7%) foi o maior entre os grupos (Kruskal-Wallis): A: 18%; C: 15,5%. Houve regularidade macroscópica da região da miotomia do grupo A e deformidades com inflamação aguda persistente e granulomas no B. No grupo A houve epitelização mesotelial e no B a superfície cruenta permaneceu granulada. Na RM do grupo B, leucócitos (22 versus 8,6 do A) e vasos (18,7 versus 9,7 da A) foram mais numerosos. A fibrose foi mais profusa no grupo B (25,85 fibras versus 15,6 no A). CONCLUSÕES: A plicatura gástrica sobre a miotomia esofagiana propicia cicatrização menos adequada e é mais demorada que a miotomia isolada.UNIFESP TOCEUNIFESPUNIFESP-EPMUNIFESP, TOCEUNIFESP, EPMSciEL

Pneumoperitoneum by using a Veress needle puncture in the left hypochondriac region: a prospective, randomized clinical trial

BACKGROUND: In the creation of the pneumoperitoneum with the Veress neddle, all reported incidents occurred during the puncture in the midline of the abdomen. Albeit rare, such type of incident has a high mortality rate as it normally severs the large vessels. The objective of this research is to test the efficacy of a safer alternative method of puncture in the left hipocondrium. METHODS: Sixty two patients, distributed randomly into two groups were studied. Group HE: puncture in the left hipocondrium (n = 30), and Group LM: puncture in the medline of the abdomen (n = 32). An evaluation was carried out of the results of the tests as to the positioning of the needle, the number of failed attempts to access the peritoneal cavity and the time taken for the creation of the pneumoperitoneum. Real flows, intraperitoneal pressure, and injected volumes were recorded at 20 second intervals, until pressure had reached 12mmHg. RESULTS: The results of the test regarding the positioning of the Needle were equally positive. There were two unsuccessful attempts at piercing in Group LM and one in Group HE. The time taken for the creation of the pneumoperitoneum was on average of 3 minutes and 46 seconds for Group HE and of 4 minutes and 2 seconds for Group LM. The average measures recorded regarding flow, pressure and volume were equivalent in each Group, respectively. The statistical analysis has demonstrated that piercing of the left hypocondrium was as effective in the creation of the pneumoperitoneum as it was the case as regards the piercing of the medium line of the abdomen. CONCLUSION: The left hipocondrium must be the preferred place for the puncture with the Veress needle so as to create the artificial pneumoperitoneum by the closed technique, as it entails a smaller risk.OBJETIVO: Na criação do pneumoperitônio com agulha de Veress por punção na linha média do abdome têm sido relatados acidentes que, apesar de raros, afetam freqüentemente os grandes vasos. O objetivo desta pesquisa é testar a eficácia da punção alternativa no hipocôndrio esquerdo e avaliar a eficácia e segurança desta punção. MÉTODO: Sessenta e dois pacientes distribuídos aleatoriamente em dois grupos foram estudados prospectivamente: grupo HE, punção no hipocôndrio esquerdo (n = 30), e grupo LM, punção na linha média do abdome (n = 32). Foram avaliados os testes de posicionamento da agulha, o número de tentativas frustradas e a duração da instalação do pneumoperitônio. Os fluxos correntes, as pressões intraperitoneais e os volumes injetados foram registrados a cada 20 segundos, até 12mmHg. RESULTADOS: Os testes de posicionamento foram positivos em ambos os grupos. Ocorreram duas tentativas infrutíferas de punção no grupo LM e uma no grupo HE. O tempo de duração para o estabelecimento do pneumoperitônio foi em média de 3 minutos e 46 segundos para o Grupo HE e de 4 minutos e 2 segundos para o grupo LM. As médias dos fluxos, das pressões e dos volumes foram respectivamente equivalentes entre os grupos. A análise estatística demonstrou que a punção no HE foi tão eficaz no estabelecimento do pneumoperitônio quanto a punção na LM do abdome. CONCLUSÕES: A punção no HE deve ser o local de escolha para a punção com agulha de Veress na criação do pneumoperitônio artificial pela técnica fechada, por ser segura e eficaz.Hospital do Servidor PúblicoUniversidade Federal de São Paulo (UNIFESP)CNPqUNIFESP Setor de VideocirurgiaUNIFESHospital do Servidor Público Setor de VideocirurgiaUNIFESP, Setor de VideocirurgiaSciEL