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OBJECTIVE: The main objectives of this study were to identify, by immunohistochemistry, possible micrometastasis in the regional lymph nodes previously considered free by conventional histopathological examination, and to assess their influence on the survival of patients with colorectal cancer that had been extirpated in a radical manner. PATIENTS AND METHODS: From 38 patients with Dukes B staging (Colorectal Carcinoma Stage II (T3 N0 M0 or T4 N0 M0)) colorectal carcinoma, 383 lymph nodes were studied in paraffin blocks that had previously been considered free by conventional histopathological examination. These were submitted to immunohistochemical study using AE1/AE3 anti-cytokeratin monoclonal antibodies to identify neoplastic epithelial cells. RESULTS: Seven lymph nodes (1.82%) in six patients (15.78%) contained micrometastasis. The survival of the patients with extirpated colorectal carcinoma staged as Dukes B who had lymph node metastasis was less than in the group of patients without micrometastasis, although these values were not statistically significant. CONCLUSION: This immunohistochemical method can be employed successfully in the detection of neoplastic cells in lymph nodes previously considered free. In this study, there was a trend towards lower survival in node-positive patients but this did not reach statistical significance.

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BACKGROUND: Spontaneous intramural hemorrhage of the duodenum due to anticoagulant therapy is rare and the treatment is controversial. OBJECTIVE: To present the acquired knowledge with the treatment of these disease. CASE REPORT: A 71-year-old women receiving for a 3 month period an anticoagulant therapy presented cervical bleeding of soft tissues and symptoms of acute pancreatitis and high small bowel obstruction. Early noninvasive diagnosis by computed tomographic scan was possible and conservative therapy proved successful in complete resolution of the pancreatitis and obstructive symptoms, with resumption of oral intake in the fourth day of treatment. The frequency of bleeding in high risk patients during warfarin therapy is reduced by less intense therapy, achieving a prothrombin time with an International Normalized Ratio of 2.0 to 3.0. RESULTS: The use of conservative treatment was helpful and the patient was discharged asymptomatic, 10 days after admission. CONCLUSION: It is suggested conservative treatment for intramural hematoma of the duodenum and recommended laparotomy only when complications occur.

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BACKGROUND: Isolated ileocecal involvement by tuberculosis in the absence of pulmonar disease is rare in Brasil, therefore causes a diagnostic dilemma as it mimics colonic malignancy and Crohn's disease. METHODS: Between 1969 and 1989, eight patients with isolated hypertrophic ileocecal tuberculosis were treated by surgery in the Gastroenterology Surgery Department of the HSPE-FMO. The most common complaint among them was abdominal pain (100%) with associated symptoms of weight loss (62.5%); nausea, vomiting, fever and general weekness appeared in half of the patients. A right iliac fossa mass was present in seven (87.5% ) of them. The mean duration of symptoms was 14.7 month (range 5-36 months). In all eight patients chest x-rays were negative for tuberculosis. Barium contrast studies showed abnormalities in all cases, but these could not be distinguished from carcinoma. Colonoscopy was helpful in establishing the diagnosis of suboclusive lesions of the ileocecal regions in three patients. Tuberculosis diagnosis was suspected in two of them because ofr the presence of granulomas in colonic biopsy material. RESULTS: Six patients were submitted to elective right hemicolectomy. The two remaining with suspect of tuberculosis were operated with signals of intestinal occlusion, and underwent a limited ileocaecal resection. The positive diagnosis of intestinal tuberculosis was made in all the patients by identification of acid-fast bacilli and by the presence of caseating granulomas in intestinal or lymph node tissue on histological examination. The outcome in all of them was favorable. They received treatment with three antituberculosis drugs over a twelve month period. CONCLUSION: Hypertrophic ileocecal tuberculosis must still be considered in the differential diagnosis of abdominal pathology localized in the right lower quadrant.

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OBJETIVO: No Brasil, a tuberculose ileocecal isolada, na ausência de tuberculose pulmonar ativa ou cicatrizada, é rara, sendo freqüentemente confundida com neoplasia e a doença de Crohn. MÉTODOS: Os autores apresentam oito doentes com essas características, tratados por cirurgia, em período de 20 anos. A dor abdominal na fossa ilíaca direita foi o principal sintoma (100 por cento), seguido da presença de perda de peso (62,5 por cento), febre, náuseas e vômitos e fadiga em 50 por cento dos doentes. Sete enfermos (87,5 por cento) apresentaram massa palpável na fossa ilíaca direita. A duraçäo média dos sintomas foi de 14,7 meses, variando de 5 a 36 meses. Todas as lesöes foram detectadas pelo enema opaco e mimetizavam aspecto neoplásico. A colonoscopia foi realizada em três doentes, evidenciando lesöes sub-oclusivas da regiäo íleo-cecal em dois; as biópsias foram sugestivas de tuberculose, näo sendo possível diferenciá-las da doença de Crohn. RESULTADOS: Seis enfermos com diagnóstico presuntivo de neoplasia foram submetidos a cirurgia eletiva, realizando-se neles a colectomia direita clássica. Os outros dois, com suspeita de tuberculose, foram operados na vigência de obstruçäo intestinal, sendo submetidos a ressecçäo limitada (ileocecectomia). O estudo anatomopatológico estabeleceu o diagnóstico final pelo encontro de necrose caseosa e de bacilos álcool ácido-resistentes no intestino ou nos linfonodos. A evoluçäo pós-operatória foi satisfatória, com pequena morbidade resolvida clinicamente. Posteriormente, todos os doentes receberam o esquema tríplice por 12 meses, variando a droga de acordo com a época do tratamento. CONCLUSÄO: Apesar de rara, a tuberculose hipertrófica ileocecal isolada freqüentemente é confundida com neoplasias e com a doença de Crohn, devendo ser lembrada no diagnóstico diferencial das lesöes localizadas no quadrante inferior direito do abdome

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The present retrospective study of 23 patients with primary gastric lymphoma had the objective of determining the role of surgical treatment on survival. All patients were submitted to gastric resection with regional lymph node removal. Nine patients (39.1%) received supplementary treatment (chemotherapy and/or radiotherapy). According to the Kiel classification, the most frequent histological type was the centroblastic (29.1%), and most patients (60.9%) had a low-grade lymphoma. According to the Ann Arbor classification, modified by Musshoff and Schmidt-Vollmer, stages were IE in 52.1%, II1E in 8.7%, II2E in 13.1%, and IV in 26.1% of the cases. Mean survival was 29.3 months. The variables that influenced survival rates were age, advanced stage tumor, and receiving postoperative adjuvant therapy. Analysis of our cases suggests that complete lesion resection along with adjacent lymph nodes, and supplementary postoperative treatment is the best approach for a resectable primary gastric lymphoma.

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Necrosis of the stomach after isolated splenectomy with the formation of gastrocutaneous fistula is a rare event that occurs in less than 1% of splenectomies. It is more frequent when the removal of the spleen is done because of hematological diseases. Its mortality index can reach 60% and its pathogenesis is controversial, as it may be attributed both to direct trauma of the gastric wall and to ischemic phenomena. Although the stomach may exhibit exuberant arterial blood irrigation, anatomical variations can cause a predisposition towards the appearance of potentially ischemic areas, especially after ligation of the short gastric vessels around the major curvature of the stomach. Once this is diagnosed in the immediate postoperative period, it becomes imperative to reoperate. The surgical procedure will depend on the conditions of the peritoneal cavity and patient's clinic status. The objective of this study was to report on the case of a patient submitted to splenectomy because of closed abdominal traumatism, who then presented peritonitis and percutaneous gastric fistula in the post-operative period. During the second operation, perforations were identified in anterior gastric wall where there had been signs of vascular stress. The lesion was sutured after revival of its borders, and the patient had good evolution. Prompt diagnosis and immediate treatment of this unusual complication are needed to reduce its high mortality rate.

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The authors describe a case of abdominal angiostrongyliasis in an adult patient presenting acute abdominal pain caused by jejunal perforation. The case was unusual, as this affliction habitually involves the terminal ileum, appendix, cecum or ascending colon. The disease is caused by the nematode Angiostrongylus costaricensis, whose definitive hosts are forest rodents while snails and slugs are its intermediate hosts. Infection in humans is accidental and occurs via the ingestion of snail or slug mucoid secretions found on vegetables, or by direct contact with the mucus. Abdominal angiostrongyliasis is clinically characterized by prolonged fever, anorexia, abdominal pain in the right-lower quadrant, and peripheral blood eosinophilia. Although usually of a benign nature, its course may evolve to more complicated forms such as intestinal obstruction or perforation likely to require a surgical approach. Currently, no efficient medication for the treatment of abdominal angiostrongyliasis is known to be available. In this study, the authors provide a review on the subject, considering its etiopathogeny, clinical picture, diagnosis and treatment.

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The authors studied the surgical treatment of patients with intestinal endometriosis. A total of 10 patients, with a median age range of 43 years, underwent an operation. Cramp abdominal pain (100%), diarrhea (30%), constipation and enterorrhagia (20%) dominated the clinical picture. At the time of surgery, four patients presented intestinal obstructive symptoms. Five (50%) patients reported gynecological complaints. Four patients were infertile and five had prior surgical gynaecological events. Seven cases presented sigmoid involvement, and three had involvement of the cecal appendix. Pre-operative diagnosis was carried out in two patients only. Surgical indications were due to suspicion of cancer (4 patients), appendicitis (3 patients), diverticular disease (1 patient) and unmanageable pain (2 patients). The following procedures were performed: left colectomy (2 cases), rectosigmoidectomy (3 cases), sigmoidectomy (3 cases), colostomy (2 cases) and three appendicectomy cases associated with concomitant gynecological interventions. No postoperative complications or deaths were observed. The authors emphasize that intestinal stenotic lesions should be treated by means of extirpation while the parietal nodule should be treated by exeresis. Intestinal endometriosis should be suspected in cases of lower abdomen recurrent pain in premenopausal infertile women or with previous surgical, gynecological events associated with intestinal symptoms or distal colon stenosis.

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BACKGROUND AND METHODS: The present study describes the procedures used by the authors in the management of 34 patients with spontaneous perforation of the small intestine. RESULTS: Only one (2.9%) of the patients had the perforation cause diagnosed before laparotomy; 27 (80%) cases showed ileal perforative lesions while seven (20%) had jejunal lesions; 31 (91.1%) patients presented single perforations and three (8.8%) had multiple ones. Intestinal resection followed by anastomosis or ileostomy and colostomy, was carried out in 21 (61.7%) cases, and 13 (38.2%) patients were submitted to exeresis with edge restoration and lesion suture. The cause of perforation could be identified in 29 (86.3%) cases while in five (14.7%) patients the cause was considered idiopathic. Eighteen (53%) patients recovered from surgery and were discharged; there were 16 (47%) deaths resulting from a number of complications. CONCLUSIONS: Since the prognosis regarding this disease depends on the peritoneal infection severity level, the patient's organic resistance, and most of all, the time interval spent until the treatment is initiated, the authors emphasize the need to have a laparotomy performed as early as possible considering that this procedure provides the best chances of survival and health recovery.

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Objetivo. Avaliar a ocorrência de lipomas colorretais, métodos diagnósticos e conduta terapêutica, com o intuito de estabelecer normas no atendimento dos portadores desta afecçäo. Casuística e Métodos. Revisadas autópsias feitas em período de 6 anos e estudados os prontuários de portadores de lipomas colorretais tratados entre 1965 e 1993, com ênfase ao quadro clínico, conduta diagnóstica e terapêutica. Os 29 portadores de lipomas intestinais submucosos foram distribuídos em três grupos. O grupo I, cujos lipomas foram detetados em necrópsias; o grupo II, com doentes sintomáticos, e um terceiro grupo de enfermos assintomáticos, com lipomas encontrados acidentalmente em peças cirúrgicas ressecadas por neoplasias ou durante procedimentos diagnósticos. Resultados. 0,6 por cento dos autopsiados apresentaram lipomas colorretais, situados, preferencialmente, no cólon direito, predominando em mulheres (70,0 por cento). No grupo II, a enterorragia foi o sintoma mais freqüente (54,5 por cento), seguida pela dor abdominal em cólica e por alteraçöes do hábito intestinal. A intussuscepçäo ocorreu em três doentes (27,3 por cento). Ao contrário da literatura, os lipomas sintomáticos localizaram-se, preferencialmente, no cólon esquerdo, sendo seu tamanho médio de 6,1cm. Os diagnósticos foram realizados por meio do enema opaco e, mais recentemente, pela colofibroscopia e tomografia computadorizada. Neste grupo, foram realizadas ressecçöes em dez doentes, sendo cinco amplas, três locais e duas endoscópicas. Um paciente eliminou, espontaneamente, seu lipoma. Lipomas múltiplos foram detetados em 30 por cento dos autopsiados e em 25 por cento do grupo assintomático. Nestes dois grupos, nenhum dos tumores era maior que 2,0cm de diâmetro. Conclusöes. Lipomas colorretais säo raros, quer na clínica diária, quer em autópsias. Antes do advento da colofibroscopia e da tomografia, a maioria dos doentes era submetida a ressecçäo extensa, na suposiçäo de doença maligna. Posteriormente, a polipectomia endoscópica e a ressecçäo local passaram a ser nossa conduta preferencial.

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OBJECT: To evaluate the incidence of colorectal lipomas, its diagnostic methodology and therapeutic management. CASUISTIC AND METHODS: The reviewed necropsies performed in a six years period and the patients' records from colorectal lipomas cases treated up to 1965 until 1993 were studied enhancing the clinical presentation, their diagnosis and therapy. The 29 cases of submucosal intestinal lipomas were disposed in three groups. The first group with ten patients lipomas were detected at necropsies. The second group with 11 symptomatic patients and group three with 8 asymptomatic patients which lipomas were discovered accidentally in surgical specimens resected due to neoplasm or in the course of diagnostical procedure. RESULTS: 0.56% of patients who were submitted to necropsy disclosed colorectal lipomas situated preferentially in right colon and in female. Enterourhage was the most often symptom (54.5%) in the group two, followed by cramp abdominal pain. Intussusception appeared in three patients (27.3%). Contrary to the medical literature, the symptomatic lipomas were preferentially situated in left colon and its mean size was 6.1 cm. The diagnosis were performed through opaque enema and more recently by colofibroscopy and CT scan. Resections were performed in all patients: five were enlarged, three were local and other three were endoscopic resections. Multiple lipomas were detected in 30% of patients who were submitted to necropsy and in 25% of asymptomatic group. In both groups no tumor was larger than 2.0 cm of diameter. CONCLUSIONS: Colorectal lipomas are rare in both clinical presentation and necropsy. Before the advent of CT scan and colofibroscopy the majority of the patients were submitted to wide resections, in the assumption of malignancy. Afterwards the endoscopic polipectomy and local resection became our preferential management.

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Tumors of nervous origin in the retroperitoneum are rare without specific symptoms which diagnosis is usually very difficult. The authors report a case of an asymptomatic patient with two benign retroperitoneal neurofibromas, one of them calcified and located near the inferior pole of the left kidney; the other tumor was closely adhered to the pancreatic tail in the supramesocolic region. Both were resected with appropriated surgical margins. The histopathologic and immunohistochemical studies established the correct diagnosis of the lesions. The authors comment the diagnostic tests of these tumors, their possible malignant degeneration and their surgical treatment.

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Twenty-one patients with carcinoid tumors have been analysed. Out of 18 patients the diagnostic was made at operation and out of 3 by autopsy. The most frequent sites of the primary tumors were the appendix (38.1%), ileum (23.8%) and colon (19.9%). Asymptomatic tumors were found incidentally in 10 patients (55.5%). The symptomatic neoplasms were more common in the ileum. No one patients in this series obtained the diagnostic of carcinoid tumors before operation or autopsy. It was not observed the malignant carcinoid syndrome. Sixteen patients (88.8%) were submitted to resection and the mean survival was 10.7 years. Two patients (11.1%) were submitted to palliative operations and the mean survival was 3.5 months. The incidence of metastases in cases with carcinoid greater than 2.0 cm in diameter was 71.4%; on the other hand, the patients with carcinoids 2.0 cm in diameter or smaller than this size disclosed metastases in 7.6%. No patients with appendix carcinoid showed metastases and all patients with metastases presented ileum or colon carcinoids. In this series, the prognostic was related with the lesion's size, the localization of the tumor in the gastrointestinal tract and with the resection or not of the primary neoplasm.

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The authors report a case of gastric epithelial leiomyoma (leiomyoblastoma). Macroscopically, such tumors resemble leiomyoma, with a biological behavior between leiomyoma and leiomyosarcoma. A review of the medical literature indicates that gastrointestinal bleeding is the most usual manifestation. Gastrointestinal seriography and endoscopy are the most utilized diagnostic exams. The endoscopic biopsy, many times, is unable to confirm the malignant or benign nature of the tumor. It is emphasized the importance of identifying the potentially malignant tendency of the tumor, indicated, mainly, by histology and mitotic counting. The treatment is surgical and consists of local or gastric resection, according to the neoplastic localization, its extension, infiltration, biological nature and the presence of multiple tumors. In the case reported, the patient was operated in urgency because of hemoperitoneum and the source of bleeding was a neoplastic vessel in the anterior wall of the antrum, which was not resected at that time. Later on, a biopsy of the gastric tumor performed during a routine surgery disclosed the real nature of the disease. Once the histopathological diagnostic was made and its potential malignant evolution detected the patient was re-operated. A partial gastrectomy with removal of the antrum was performed. Now, the patient has been asymptomatic with no evidences of metastasis after 30 months of the diagnostic.

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Foram estudados 24 pacientes portadores de ulcera peptica pos-gastrectomia parcial tratados exclusivamente pela vagotomia troncular, usando-se preferencialmente a via toracica como acesso. Os resultados precoces demonstraram ausencia de mortalidade pos-operatoria e morbidade muito reduzida. Os resultados tardios apresentam baixos indices de recidiva ulcerosa e nao exibiram quadros importantes de diarreia, demonstrando, portanto, ser um metodo bastante eficiente e com amplas possibilidades de emprego no tratamento das ulceras pepticas pos-gastrectomias

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Sao analisadas 59 observacoes de um total de 65 doentes com pancreatite cronica tratados cirurgicamente no Servico de Gastroenterologia Cirurgica do Hospital do Servidor Publico Estadual de Sao Paulo. A ingestao prolongada e continua de alcool foi relatada por 47 pacientes. De acordo com a conduta, dividiu-se o material em grupos incluindo resseccoes pancreaticas cefalicas ou de corpo e cauda, derivacoes pancreatointestinais ou operacoes associadas. Os niveis de amilasemia foram estudados antes e depois das intervencoes, tendo revelado serem um bom indice para se apreciar o efeito do tratamento. Os resultados clinicos da cirurgia foram bons em carca de dois tercos dos doentes, cuidando-se que a operacao deve ser planejada de acordo com as caracteristicas clinicas, radiologicas e anatomo-patologicas do pancreas de cada doente

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