Large intestine obstruction complicated with perforation: a rare manifestation of Schistosoma mansoni infection

The authors report a case of a 25 year old Brazilian man with a history of crampy abdominal pain in the left iliac fossa for 2 weeks, abdominal distention, mucous diarrhea and anorexia. The patient presented signs of hemodynamic instability and a hard mass palpated in the left iliac fossa presented peritoneal irritation. At laparotomy, fecal peritonitis and a punched-out perforation of the midsigmoid colon were found. A left hemicolectomy was performed with terminal colostomy. Specimen examination revealed a thickened rectosigmoid wall, narrow lumen and multiple mucosal polyps. Microscopically, chronic granulomatous colitis with Schistosoma mansoni eggs confirmed the etiology. To the authors' knowledge, this is the first case of obstruction complicated with perforation due to mansoni schistosomiasis reported in the literature.Os autores relatam o caso de um paciente masculino, de 25 anos, admitido com história de dor em cólica na fossa ilíaca esquerda há duas semanas, distensão abdominal, diarréia mucóide e anorexia. Evoluiu com instabilidade hemodinâmica, uma massa endurecida era palpada na fossa ilíaca esquerda com sinais de irritação peritoneal. Na laparotomia, foram encontrados peritonite fecal e uma perfuração do cólon sigmóide. Realizada hemicolectomia esquerda com colostomia terminal. O exame anátomo-patológico revelou espessamento da parede do cólon com estreitamento de sua luz e múltiplos pólipos na mucosa. O exame histopatológico confirmou a causa da obstrução como colite granulomatosa crônica com ovos viáveis de Schistosoma mansoni. Este é o primeiro caso de obstrução colônica complicada com perfuração causada por esquistossomose mansônica relatado na literatura consultada.Universidade Federal de São Paulo (UNIFESP)Escola Paulista de MedicinaUNIFESP, EPMSciEL

Does mesenchymal stem cell improve the liver regeneration after the 70% hepatectomy?]

Purpose: To evaluate the effects of mesenchymal stem cells on liver regeneration in rats following a 70% hepatectomy. Methods: Forty rats were subjected to 70% hepatectomy and then similar to 10(6) mesenchymal stem cells (test group), or saline solution (control group), were infused into their livers via the portal vein. Each treatment group was divided into early and late subgroups (euthanized 3 d and 5 d following the operation, respectively). Group comparisons of Albumin, aminotransaminases (AST, ALT), and Alcaline Phosphatase (AP) levels, proliferative index (ki-67+ straining), and mitotic cell counts were conducted. Results: No significant differences in liver regeneration rate, number of mitoses, proliferative index, or serum levels of albumin, AST, or AP were observed. ALT levels were higher in the test group than in the control group (p<.05). Conclusions: Mesenchymal stem-cell therapy did not improve liver regeneration rate 3 d or 5 d after 70% hepatectomy in rats. Likewise, the therapy appeared not to affect liver function, proliferative index, or number of mitoses significantly.Univ Fed Sao Paulo UNIFESP, Postgrad Program Interdisciplinary Surg Sci, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Dept Pathol, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, Dept Surg, Div Surg Gastroenterol, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, Postgrad Program Interdisciplinary Surg Sci, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Dept Pathol, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, Dept Surg, Div Surg Gastroenterol, Sao Paulo, SP, BrazilWeb of Scienc

An evaluation of the protective effect of an infusion of chilled glucosesolution on thermal injury of the bile ducts caused by radiofrequency ablation of the liver

PURPOSE: To evaluate the protective effects of chilling the bile ducts with cold (5°C) 5% glucose solution (GS) during radiofrequency (RF) administration. METHODS: Twenty male pigs (3 mos. old; 25-30 kg) were subjected to RF delivery with chilling (experimental group, N=10) or without chilling (control group, N=10). Half of the animals in each group were euthanized immediately after the operation, and half were euthanized one week later. The following histological variables in relation to the bile ducts were evaluated by a pathologist (blind examiner): degenerative changes to the epithelium; epithelial necrosis; ulceration, regenerative changes of the epithelium; polymorphonuclear neutrophil infiltration; and thermal effects. RESULTS: The experimental group (88 bile ducts examined) showed reduced thermal damage relative to the control group (86 bile ducts examined) as demonstrated by significant differences in the following histopathological parameters: epithelial detachment of biliary epithelium (84.1% vs. 59.3%; p<0.006); elongation/palisade arrangement of nuclei (65.1% vs. 87.5%; p<0.001); pseudo-goblet cells (32.9% vs. 56.8%; p<0.001). CONCLUSION: Infusion of 5% glucose solution (5°C) has a protective effect on bile duct subjected to heat (95-110°C, 12 min) from radiofrequency thermal ablation device.Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Federal University of São PauloUniversidade Federal de São Paulo (UNIFESP) Department of PathologyUniversidade Federal de São Paulo (UNIFESP) Department of SurgeryAlbert Einstein Israelite Hospital Department of Image DiagnosticUNIFESP School of MedicineUNIFESP, Department of PathologyUNIFESP, Department of SurgeryUNIFESP, School of MedicineSciEL

Financial cost of the admissions for simultaneous pancreas-kidney transplant in a Brazilian Hospital

PURPOSE:To perform a cost analysis of simultaneous pancreas-kidney transplantation (SPKT) in a Brazilian hospital.METHODS:Between January 2008 and December 2011, 105 consecutive SPKTs at the Hospital of Kidney and Hypertension in São Paulo were evaluated. We evaluated the patient demographics, payment source (public health system or supplementary system), and the impact of each hospital cost component. The evaluated costs were corrected to December 2011 values and converted to US dollars.RESULTS:Of the 105 SPKT patients, 61.9% were men, and 38.1% were women. Eight patients died, and 97 were discharged (92.4%). Eighty-nine procedures were funded by the public health system. The cost for the patients who were discharged was $18.352.27; the cost for the deceased patients was$18.449.96 (p = 0.79). The FOR for SPKT during this period was positive at $5,620.65. The costs were distributed as follows: supplies, 36%; administrative costs, 20%; physician fees, 15%; intensive care unit, 10%; surgical center, 10%; ward, 9%.CONCLUSION:Mortality did not affect costs, and supplies were the largest cost component.Federal University of São Paulo Department of SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of SurgeryHypertension and Kidney HospitalUniversidade Federal de São Paulo (UNIFESP) Department of Internal MedicineUniversidade Federal de São Paulo (UNIFESP) Department of PediatricUNIFESP, Department of SurgeryUNIFESP, Department of SurgeryUNIFESP, Department of Internal MedicineUNIFESP, Department of PediatricSciEL

Use of fibrinogen and thrombin sponge in pediatric split liver transplantation

Purpose: To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation. Methods: Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge). Results: The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%)p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 +/- 102.38 mL/kg) than that in Group B (35.1 +/- 41.67 mL/kg)p = 0.048. Regarding bile leak there was no statistical difference. Conclusion: The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.Univ Fed São Paulo UNIFESP, Postgrad Program Interdisciplinary Surg Sci, São Paulo, BrazilUniv Fed São Paulo, Dept Surg, Div Surg Gastroenterol, São Paulo, SP, BrazilUniv Fed São Paulo, Dept Surg, Div Pediat Surg, São Paulo, SP, BrazilUniv Fed São Paulo UNIFESP, Dept Surg, Div Surg Gastroenterol, São Paulo, SP, BrazilUniv Fed São Paulo UNIFESP, Postgrad Program Interdisciplinary Surg Sci, São Paulo, BrazilUniv Fed São Paulo, Dept Surg, Div Surg Gastroenterol, São Paulo, SP, BrazilUniv Fed São Paulo, Dept Surg, Div Pediat Surg, São Paulo, SP, BrazilUniv Fed São Paulo UNIFESP, Dept Surg, Div Surg Gastroenterol, São Paulo, SP, BrazilWeb of Scienc

Acompanhamento de longo prazo após a ressecção de metástases na tiroide de carcinoma hepatocelular em fígado cirrótico

Thyroid metastasis from hepatocellular carcinoma (HCC) is rare, and has poor prognosis. We report the case of a 62-year-old woman seen at our clinic because of the occurrence of a slightly painful abdominal mass. At that time, alpha-fetoprotein concentration was very high, reaching 49,831.7 ng/mL. Abdominal ultrasound showed a heterogeneous mass in segment IV of the liver, which was diagnosed as HCC upon MRI. The patient underwent surgical resection and histological analysis of the specimen confirmed HCC. Metastases to the thyroid were detected 17 months after liver resection. Although the presence of metastases indicates advanced disease, thyroidectomy was performed, since no other distant metastases were detected. In fact, the patient is doing well 3 years after thyroidectomy and regular imaging exams showed no tumor recurrence. Current alpha-fetoprotein concentration is 8 ng/mL. In conclusion, thyroid metastasis from HCC is uncommon and short-term survival is expected. However, surgical resection should be encouraged, especially in the case of solitary metastases.As metástases de carcinoma hepatocelular (CHC) em tiroide são raras e o prognóstico é ruim. Relatamos o caso de uma paciente de 62 anos de idade atendida em nossa clínica devido a uma massa abdominal levemente dolorida. Naquele momento, a concentração de alta-fetoproteína era muito alta, chegando a 49.831,7 ng/mL. O ultrassom de abdômen mostrou uma massa heterogênea no segmento IV do fígado, que foi diagnosticada como CHC por meio de ressonância magnética. A paciente foi submetida a uma ressecção cirúrgica, e a análise histológica do espécime confirmou o CHC. As metástases na tiroide foram detectadas 17 meses após a ressecção do fígado. Embora a presença de metástases indique doença avançada, a tiroidectomia foi feita porque não foram detectadas outras metástases distantes. De fato, três anos após a tiroidectomia, a paciente está bem e os exames de rotina mostraram não haver recorrência do tumor. A concentração atual de alfa-fetoproteína é de 8 ng/mL. Concluiu-se que as metástases de CHC em tiroide não são comuns e espera-se uma sobrevida curta. Entretanto, deve-se encorajar a ressecção cirúrgica, especialmente no caso de metástases solitárias.Universidade Federal de São Paulo (UNIFESP) Hepatology Unit Department of GastroenterologyUNIFESP Liver Transplant Unit Department of SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Pediatric SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Diagnostic RadiologyUniversidade Federal de São Paulo (UNIFESP) Department of PathologyUNIFESP, Hepatology Unit Department of GastroenterologyUNIFESP, Liver Transplant Unit Department of SurgeryUNIFESP, Department of Pediatric SurgeryUNIFESP, Department of Diagnostic RadiologyUNIFESP, Department of PathologySciEL

Pancreas and islet transplantation in patients with diabetes mellitus

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.Universidade Federal de São Paulo (UNIFESP) Departamento de Medicina Departamento de CirurgiaPontifícia Universidade Católica do Rio Grande do Sul Hospital São Lucas Serviço de NefrologiaUniversidade de São Paulo Núcleo de Terapia Celular e MolecularSistema de Saúde Centro de Pesquisa Médica Notre-Dame IntermédicaUSP Faculdade de Medicina Departamento de Clínica MédicaUniversidade Federal do Rio Grande do Sul Departamento de Medicina InternaHospital Israelita Albert Einstein Serviço de Transplante de PâncreasUNIFESP, Depto. de Medicina Depto. de CirurgiaSciEL