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Colorectal cancer (CRC) represents the second deadliest malignancy worldwide. Around 75% of CRC patients exhibit high levels of chromosome instability that result in the accumulation of somatic copy number alterations. These alterations are associated with the amplification of oncogenes and deletion of tumor-ppressor genes and contribute to the tumoral phenotype in different malignancies. Even though this relationship is well known, much remains to be investigated regarding the effect of said alterations in long non-coding RNAs (lncRNAs) and, in turn, the impact these alterations have on the tumor phenotype. The present study aimed to evaluate the role of differentially expressed lncRNAs coded in regions with copy number alterations in colorectal cancer patient samples. We downloaded RNA-seq files of the Colorectal Adenocarcinoma Project from the The Cancer Genome Atlas (TCGA) repository (285 sequenced tumor tissues and 41 non-tumor tissues), evaluated differential expression, and mapped them over genome sequencing data with regions presenting copy number alterations. We obtained 78 differentially expressed (LFC > 1|< -1, padj < 0.05) lncRNAs, 410 miRNAs, and 5028 mRNAs and constructed a competing endogenous RNA (ceRNA) network, predicting significant lncRNA-miRNA-mRNA interactions. Said network consisted of 30 lncRNAs, 19 miRNAs, and 77 mRNAs. To understand the role that our ceRNA network played, we performed KEGG and GO analysis and found several oncogenic and anti-oncogenic processes enriched by the molecular players in our network. Finally, to evaluate the clinical relevance of the lncRNA expression, we performed survival analysis and found that C5orf64, HOTAIR, and RRN3P3 correlated with overall patient survival. Our results showed that lncRNAs coded in regions affected by SCNAs form a complex gene regulatory network in CCR.
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RESUMEN Los pacientes que reciben anticoagulación y que presentan lesiones traumáticas craneales están en riesgo aumentado de presentar fenómenos hemorrágicos a nivel intracraneal. La mortalidad en esta clase de pacientes es elevada lo que los convierte en una población que amerita un cuidadoso abordaje y seguimiento. Usualmente los pacientes que observamos en servicios de urgencia son traumas craneales leves pero la evolución del paciente anticoagulado en algunos casos es impredecible. Actualmente, han sido publicados diversos estudios con relación a anticoagulación y lesión traumática cerebral. Presentamos una concisa revisión de la literatura enfocada a médicos neurólogos y neurocirujanos.
Abstract Patients receiving anticoagulation and those with traumatic cranial lesions are at increased risk of hemorrhagic phenomena at the intracranial level. Mortality in this class of patients is high, which makes them a population that deserves a careful approach and follow-up. Usually the patients we observe in emergency services are mild cranial traumas but the evolution of the anticoagulated patient in some cases is unpredictable. Currently, several studies have been published in relation to anticoagulation and traumatic brain injury. We present a concise review of the literature focused on neurologists and neurosurgeons.
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Meningeal tuberculosis is a severe type of extrapulmonary disease, which is thought to begin with respiratory infection, followed by hematogenous dissemination and brain infection. Host genetic susceptibility factors and specific mycobacterial substrains could be involved in its development. From an epidemiological study in Colombia, we selected three Mycobacterium tuberculosis clinical strains isolated from the cerebrospinal fluid (CSF) of patients with meningeal tuberculosis, and used them to infect BALB/c mice through the intratracheal route. These strains showed a distinctive spoligotype pattern. The course of infection in terms of strain virulence (mice survival, bacillary loads in lungs), bacilli dissemination and extrapulmonary infection (bacilli loads in blood, brain, liver, kidney and spleen), and immune responses (cytokine expression determined by real time PCR in brain and lung) was studied and compared with that induced by the laboratory strain H37Rv and other five clinical strains isolated from patients with pulmonary TB. All the clinical isolates from meningeal TB patients disseminated extensively through the hematogenous route infecting the brain, producing inflammation in the cerebral parenchyma and meninges, whereas H37Rv and clinical isolates from pulmonary TB patients showed very limited efficiency to infect the brain. Thus, it seems that mycobacterial strains with a distinctive genotype are able to disseminate extensively after the respiratory infection and infect the brain.
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Modelos Animais de Doenças , Mycobacterium tuberculosis/genética , Tuberculose Meníngea/microbiologia , Adulto , Animais , Carga Bacteriana , Colômbia/epidemiologia , Contagem de Colônia Microbiana , Citocinas/biossíntese , Citocinas/genética , Progressão da Doença , Genes Bacterianos , Genótipo , Humanos , Pulmão/microbiologia , Masculino , Camundongos , Camundongos Endogâmicos BALB C , Pessoa de Meia-Idade , Mycobacterium tuberculosis/crescimento & desenvolvimento , Mycobacterium tuberculosis/isolamento & purificação , Mycobacterium tuberculosis/patogenicidade , Tuberculose Meníngea/epidemiologia , Tuberculose Meníngea/patologia , Tuberculose Pulmonar/microbiologia , Tuberculose Pulmonar/patologia , VirulênciaRESUMO
The protective effect of human gamma globulins on Mycobacterium tuberculosis infection was evaluated in a mouse model of intratracheal infection. Animals receiving human gamma globulins intranasally, 2h before intratracheal challenge showed a significant decrease in lung bacilli load compared to non-treated animals in different time intervals of up to 2 months after challenge. The same effect was obtained when M. tuberculosis was pre-incubated with the gamma globulin before challenge. The protective effect of the gamma-globulin formulation was abolished after pre-incubation with M. tuberculosis. These results suggest a potential role of specific antibodies in the defence against mycobacterial infections.
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Fatores Imunológicos/administração & dosagem , Mycobacterium tuberculosis/efeitos dos fármacos , Tuberculose Pulmonar/prevenção & controle , gama-Globulinas/administração & dosagem , Administração Intranasal , Animais , Contagem de Colônia Microbiana , Fatores Imunológicos/imunologia , Masculino , Camundongos , Camundongos Endogâmicos BALB C , Mycobacterium tuberculosis/imunologia , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Pulmonar/microbiologia , gama-Globulinas/imunologiaRESUMO
The environmental saprophyte Mycobacterium vaccae induces a Th1 response and cytotoxic T cells that recognize M. tuberculosis, and by subcutaneous injection, it is therapeutic for pulmonary tuberculosis (TB) induced by high-dose challenge in BALB/c mice. However, M. vaccae also drives regulatory T cells that inhibit Th2 responses, and this is seen in allergy models, not only following subcutaneous injection but also after oral administration. An oral immunotherapeutic for TB would be clinically useful, so we investigated M. vaccae given orally by gavage at 28-day intervals in the TB model. We used two different protocols: starting the oral M. vaccae either 1 day before or 32 days after infection with M. tuberculosis. Throughout the infection (until 120 days), we monitored outcome (CFU), molecules involved in the development of immunoregulation (Foxp3, hemoxygenase 1, idoleamine 2,3-dioxygenase, and transforming growth factor beta [TGF-beta]), and indicators of cytokine balance (tumor necrosis factor, inducible nitric oxide synthase, interleukin-4 [IL-4], and IL-4delta2; an inhibitory splice variant of IL-4 associated with improved outcome in human TB). Oral M. vaccae had a significant effect on CFU and led to increased expression of Th1 markers and of IL-4delta2, while suppressing IL-4, Foxp3, and TGF-beta. When administered 1 day before infection, oral M. vaccae induced a striking peak of expression of hemoxygenase 1. In conclusion, we show novel information about the expression in TB of murine IL-4delta2 and molecules involved in immunoregulation and show that these can be modulated by oral administration of a saprophytic mycobacterium. A clinical trial of oral M. vaccae in extensively drug-resistant TB might be justified.
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Fatores Imunológicos/uso terapêutico , Imunoterapia/métodos , Mycobacterium/imunologia , Vacinas contra a Tuberculose/uso terapêutico , Tuberculose Pulmonar/imunologia , Tuberculose Pulmonar/terapia , Administração Oral , Animais , Contagem de Colônia Microbiana , Citocinas/biossíntese , Injeções Subcutâneas , Pulmão/imunologia , Pulmão/microbiologia , Masculino , Camundongos , Camundongos Endogâmicos BALB CRESUMO
INTRODUCTION: Nissen funduplication is each time more frequently used for gastroesophageal reflux disease (GERD) treatment. Surgical technique has changed from open to laparoscopic. OBJECTIVE: To analyze in comparative form the results of open and laparoscopic Nissen procedure. MATERIAL AND METHODS: In a period of five years, Nissen funduplication was practiced to 144 patients with confirmed GERD (50 open and 94 laparoscopic). All the patients were follow-up in Outpatient Consultation of the hospital for a minimum period of a year, evaluating in comparative form results and complications of the intervention. Retrospective revision of the files was made. RESULTS: Surgical time average in open surgeries was of 2.6 hours, and laparoscopic 2.57 hours (p = ns). Splenectomy in a patient operated in open form was an only complication. Postoperating complications in four patients (5%) laparoscopic and in 10 (20%) open (p 0.002). Hospital stay in these last ones was of 7.6 days and in laparoscopic 4.7 days (p < 0.0001). A year after the intervention, 19 patients (38%) open surgeries presented suggestive symptoms of reflux or had proton pump inhibitors (PPIs). Of these, in 5 (10%) recurrence of the GERD by some method was confirmed requiring reoperation two of them. In five peptic acid gastro/duodenal disease was confirmed and the rest had drugs without specific indication, demonstrating suitable morphology of the SEGD intervention. In the laparoscopic group, there were 26 symptomatic patients or who had PPIs a year after the intervention (27%). In seven (7%) reflux recurrence was confirmed, becoming necessary the reintervention in two. Another gastric/duodenal pathology in 13 was documented and six had drugs without specific indication. CONCLUSIONS: Nissen operation allows reflux control in 90% of the patients. Laparoscopic intervention requires a smaller hospital stay and is associated to less frequency of complications. The accomplishment of all technical steps of Nissen surgery, open or laparoscopic, is indispensable for good results.
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Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Laparoscopia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION: There is no information in the literature about surgical outcome of the distal splenorenal shunt (Warren shunt) in those patients with anomalous flow in the left renal vein to the inferior vena cava. OBJECTIVE: The purpose of this manuscript was to evaluate the incidence of thrombosis in the Warren shunt in those patients with anomalous flow in the left renal vein to the inferior vena cava. METHODS: We performed a prospective, descriptive and longitudinal study in those patients who performed a surgical procedure to the treatment of hemorrhagic portal hypertension in a tertiary referral center in Mexico City during a one year period (2002-2003). Before the surgical procedure an arterial and venous angiographic study was done including celiac axis, superior mesenteric artery and splenic artery. The patients were scheduled in the outpatient office the first, third, sixth month and the year after the surgical procedure. We looked in them for gastrointestinal bleeding secondary to portal hypertension. In those patients with Warren shunt an angiographic study was done during the first month after the surgical procedure. RESULTS: Twenty eight patients were included, 17 of them women (60.7%). Median patient age was 48 years old. In 20 patients a Warren shunt were done and in eigth patients a devascularization operation were done. The anomalous flow of the left renal vein was identified in nine patients (28.7%). In seven of them a Warren shunt were done and in two of them a devascularization operation were done. We didn't find gastrointestinal bleeding or thrombosis of the Warren shunt in any of these patients. CONCLUSION: In those cases of patients with anomalous flow in the left renal vein a Warren shunt can be performed. In this study we didn't find thrombosis of the shunt or gastrointestinal bleeding. In this way a surgical decompression of the portal system can be done preventing bleeding episodes.
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Hemorragia Gastrointestinal/fisiopatologia , Hipertensão Portal/fisiopatologia , Derivação Esplenorrenal Cirúrgica , Pressão Sanguínea , Feminino , Hemorragia Gastrointestinal/complicações , Humanos , Hipertensão Portal/complicações , Masculino , Estudos Prospectivos , Veias Renais/fisiopatologia , Veia Esplênica/fisiopatologiaRESUMO
A variant of bilioenteric anastomosis, laterolateral hepatojejunostomy, is described in which the opened anterior aspect of the common hepatic duct and left hepatic duct is anastomosed to a Roux jejunal limb. This technique is specially designed for thin, injured bile ducts in which a conventional anastomosis is difficult due to the small diameter of the ducts. A wide anastomosis is obtained, leaving the posterior wall as a conduit for bile, ensuring an adequate anastomotic diameter.
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Ducto Hepático Comum/lesões , Ducto Hepático Comum/cirurgia , Doença Iatrogênica , Jejuno/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Anastomose Cirúrgica , Seguimentos , Humanos , Complicações Intraoperatórias , Resultado do TratamentoRESUMO
INTRODUCTION: T tubes can be placed in the bile ducts either open or laparoscopically for several reasons such as: extraction of stones, biliary reconstruction after liver transplant and in end-to-end anastomosis in iatrogenic injuries. Inadequate placement of the T tube, long term stay and technical difficulties that can affect the outcome, can lead to an injury that usually requires a biliodigestive reconstruction. METHODS: In a 15-year period (1990-2005) a total of 343 patients have been referred to our university hospital for biliary reconstruction. Files of those patients in which the injury was due to misplacement of a T tube or associated with a long-term stay were reviewed. We evaluated the type of injury, technique used for the reconstruction, longterm staying of the T tubes (1-6 months), hospital in stay, long term outcomes as well as associated comorbidities. RESULTS: In 42 cases a biliary injury related to a T tube was identified (13%). All the injuries were classified as Strasberg E, with demonstration of a fistula (internal or external); 18 to the duodenum, 5 to the jejunum-ileum and 3 to the colon. A hepatojejunostomy was done to all patients; the duodenum and small gut fistulas were closed and in the 3 cases with colonic injury a right hemicolectomy was performed. The postoperative evolution was adequate without major complications but with a longer hospital stay. In 39 of the 42 patients (92%), good postoperative results were obtained. Only one case required a new surgery (22 months after the first one), due to recidivant cholangitis. CONCLUSION: Inadequate placement of the T tubes and long-term stay can produce complex biliary injuries with associated comorbidities such as fistulas to the adjacent viscera. Placement of T tubes need a careful surgical technique and their indication must be carefully assessed.
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Ductos Biliares/lesões , Doença Iatrogênica/epidemiologia , Complicações Intraoperatórias/epidemiologia , Laparoscopia/efeitos adversos , Laparotomia/efeitos adversos , Adulto , Idoso , Anastomose Cirúrgica/métodos , Doenças dos Ductos Biliares/diagnóstico , Doenças dos Ductos Biliares/cirurgia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Incidência , Complicações Intraoperatórias/etiologia , Laparotomia/métodos , Masculino , Pessoa de Meia-Idade , Procedimentos de Cirurgia Plástica/métodos , Reoperação , Estudos Retrospectivos , Medição de RiscoRESUMO
HYPOTHESIS: The addition of molgramostim (recombinant human granulocyte-macrophage colony-stimulating factor) to antibiotic therapy for nontraumatic and generalized abdominal sepsis is effective and has a significant impact on length of hospitalization, direct medical costs, and mortality. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Tertiary referral center. PATIENTS: Fifty-eight patients with abdominal sepsis. INTERVENTIONS: Patients were allocated to receive, in addition to ceftriaxone sodium, amikacin sulfate, and metronidazole, molgramostim in a daily dosage of 3 microg/kg for 4 days (group 1) or placebo (group 2). Antibiotics were administered for at least 5 days and discontinued after clinical improvement had occurred and white blood cell count had been normal for 48 hours. MAIN OUTCOME MEASURES: Time to improvement, duration of antibiotic therapy, hospital stay, complications, mortality, and adverse reactions to drugs. RESULTS: Median time to improvement was 2 days in group 1 and 4 days in group 2 (P<.005). Median length of hospitalization was 9 and 13 days, respectively (P<.001), and median duration of antibiotic therapy was 9 and 13 days, respectively (P<.001). Numbers of infectious complications in the 2 groups were, respectively, 6 and 16 (P = .02); of residual abscesses, 3 and 5; and of deaths, 2 and 2. Costs per patient were 12,333 dollars and 16,081 dollars (US dollars), respectively. CONCLUSION: Addition of molgramostim to antibiotic therapy reduces the rate of infectious complications, the length of hospitalization, and costs in patients with nontraumatic abdominal sepsis.
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Antibacterianos/uso terapêutico , Antineoplásicos/uso terapêutico , Fator Estimulador de Colônias de Granulócitos e Macrófagos/uso terapêutico , Peritonite/complicações , Sepse/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amicacina/uso terapêutico , Ceftriaxona/uso terapêutico , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Tempo de Internação/tendências , Masculino , Metronidazol/uso terapêutico , Pessoa de Meia-Idade , Peritonite/tratamento farmacológico , Proteínas Recombinantes/uso terapêutico , Sepse/etiologia , Sepse/mortalidade , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
In utero fetuses are evidently exposed to several factors that cause an interruption of the oxygen flow through the umbilical cord causing asphyxia leading to hypoxia and metabolic acidosis. These conditions are important causes of intra-partum and neonatal mortality. The main objective of this review is to provide current information regarding the pathophysiology of asphyxia in piglets around parturition; the physiological mechanisms invoked by affected piglets to compensate perinatal hypoxemia are discussed. This review also addresses some similarities and differences of asphyxia between piglets and other mammals, including human neonates. Metabolic acidosis and hypoxia are sequela to asphyxia and can cause profound health effects in postnatal performance because of an abnormal suckling, a reduced absorption of colostrum and inadequate passive transfer of neonatal immunity. Acidosis also cause hypothermia, increased mortality and reduced survival in neonates. One of the first deleterious effects of intrauterine hypoxia is the expulsion of meconium into the amniotic sac leading to meconium staining of the skin, and in severe cases, meconium aspiration into the lungs. Even though there have been technological changes and improvements in husbandry, piglet mortality due to asphyxia remains a major problem. One potential alternative to reduce neonatal mortality in pigs is the monitoring of fetal stress during birth and the implemention of strategies such as the Apgar score, that is often used in human pediatrics. It is also important to consider the physiological, behavioral and biochemical changes that take place during parturition which subsequently impact the vitality, maturity and development of neonatal pigs. Understanding the pathophysiology of fetal hypoxia should help practitioners and farmers implement more effective delivery techniques aimed at reducing neonatal mortality and improving postnatal performance.
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Asfixia Neonatal/fisiopatologia , Doenças dos Suínos/fisiopatologia , Acidose/etiologia , Acidose/veterinária , Animais , Animais Recém-Nascidos , Asfixia Neonatal/complicações , Asfixia Neonatal/veterinária , Ordem de Nascimento , Regulação da Temperatura Corporal , Morte Fetal/etiologia , Morte Fetal/veterinária , Humanos , Hipóxia Encefálica/etiologia , Hipóxia Encefálica/veterinária , Recém-Nascido , Síndrome de Aspiração de Mecônio/etiologia , Síndrome de Aspiração de Mecônio/veterinária , Suínos , Fatores de TempoRESUMO
UNLABELLED: Most iatrogenic bile duct injuries are recognized in the early postoperative period (first 48 hours). These patients usually have additional complications such as a suboptimal hydroelectrolitic status, subhepatic collections, external biliary fistula and malnutrition. In these circumstances, besides the elevation of bilirubin and transaminases associated with the injury, hypoalbuminemia is frequently encountered. The timing for repair is decided according to the condition of each patient. We report the impact of preoperative abnormal low serum albumin levels on the results of biliary tract reconstruction after a iatrogenic biliary lesion. METHOD: Patients who underwent biliary reconstruction in our center from 1998 to 2002 were analyzed. Only patients with complex injuries (Strasberg E, Bismuth III-IV, Stewart-Way III) were included. Major postoperative complications were recorded and correlated with preoperative liver function tests. RESULTS: Seventy seven patients were analyzed. In 41 cases, the injury was a consequence of a laparoscopic operation. All patients were treated by a Roux-en-Y hepatojejunostomy. No operative mortality was recorded. The most frequent postoperative complications were postoperative biliary fistula (8/77-9%, p < 0.017) and subhepatic collections (9/77-9%, p < 0.39). All fistulae closed spontaneously and the subhepatic collections were drained. Overall, complications were more common in the group with hypoalbuminemia (p < 0.002). CONCLUSION: Early repair is indicated if there is no systemic contraindication (sepsis, multiple organic failure, electrolytic imbalance). Abnormalities in the liver function tests, particularly a low serum albumin, should not delay the operation. Although significantly more postoperative complications are observed in an early repair, long-term results are comparable to those of an elective repair.
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Ductos Biliares/lesões , Doenças Biliares/cirurgia , Laparoscopia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Albumina Sérica , Adolescente , Adulto , Idoso , Anastomose em-Y de Roux/efeitos adversos , Fístula Biliar/sangue , Fístula Biliar/diagnóstico , Fístula Biliar/etiologia , Contraindicações , Diagnóstico Precoce , Feminino , Humanos , Doença Iatrogênica , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , ReoperaçãoRESUMO
CONTEXT: Atypical regeneration can mimic carcinoma in various epithelia. On endoscopic biopsies, atypical regenerative hyperplasia of the esophagus may show pleomorphism and atypia, simulating esophageal squamous cell carcinoma. OBJECTIVE: To establish the most useful histologic features to distinguish atypical regenerative hyperplasia from esophageal carcinoma in endoscopic biopsies. DESIGN: To study the frequency and histologic appearance of atypical regenerative hyperplasia, which simulate carcinoma, we reviewed 600 endoscopic biopsies (555 with chronic esophagitis and 45 with carcinomas of the esophagus). We selected those cases in which the differential diagnosis included regenerative atypical hyperplasia versus esophageal carcinoma and cases of atypical regenerative hyperplasia that were mistaken for carcinoma. For comparative purposes, we studied 10 cases of esophageal carcinoma from endoscopic biopsies that were confirmed by esophagectomy. RESULTS: Among the cases with chronic esophagitis, we found 10 biopsies (1.8%) in which atypical regenerative hyperplasia mimicked carcinoma. In 7 cases, there were 4 to 12 years of follow-up, and no patient developed esophageal neoplasm. The remaining 3 patients were submitted to esophagectomy. None of these patients had carcinoma or dysplasia in the esophageal resection (false-positive biopsies). The most useful architectural changes in squamous carcinoma included stromal infiltration by nests, cords, or thin prongs of neoplastic keratinocytes, palisading desmoplasia, and in situ carcinoma in the adjacent epithelium. Malignant keratinocytes showed variable degrees of differentiation with differently shaped and sized cells, squamous epithelial pearls, individual keratinization, and atypical mitosis. In contrast, biopsies with atypical hyperplasia showed detached nests or irregular fragments without stroma and were made up of immature and relatively monotonous medium or small keratinocytes that were intermixed with inflammatory cells. Individual keratinization was rare, and no squamous pearls were seen. Other features of atypical hyperplasia included granulated tissue with atypical endothelial cells, nonatypical mitosis, lymphoid hyperplasia, and the absence of dysplasia or carcinoma in situ. Two biopsies showed stromal pseudoinfiltration as a result of tangential sectioning and were characterized by thick, round prongs composed of keratinocytes that penetrated regions with granulation or the inflamed tissues of esophageal ulcers. CONCLUSIONS: Atypical esophageal regenerative hyperplasia may mimic carcinoma in a small percentage of esophageal biopsies. If the histologic changes are not sufficient to establish an accurate diagnosis, medical treatment and subsequent biopsies should be performed, particularly if there are no endoscopic or radiologic data to support the presence of a neoplasm.
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Carcinoma de Células Escamosas/diagnóstico , Endoscopia Gastrointestinal/métodos , Neoplasias Esofágicas/diagnóstico , Esôfago/patologia , Esôfago/fisiologia , Regeneração/fisiologia , Idoso , Idoso de 80 Anos ou mais , Biópsia/métodos , Diagnóstico Diferencial , Esofagite/patologia , Esôfago/anatomia & histologia , Feminino , Humanos , Hiperplasia/diagnóstico , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND/AIMS: Cystic disease of the biliary tract (CDBT) is characterized by varying degrees of dilatation of the biliary system with high morbidity and mortality in which the surgical management is the corner stone of treatment. The cyst-enterostomies (CE) temporarily solve the obstruction to the biliary flow but have a high long-term morbidity. Complete resection of affected bile ducts with Roux-en-Y derivation (CRR-en-Y) is a good procedure with low mortality and complications. The purpose of the study was to analyze the outcome of CRR-en-Y versus CE in the treatment of CDBS in adult patients from 1970 to 2002. METHODOLOGY: Patients who underwent surgical treatment were divided for their analysis into two groups: Group I: CRR-en-Y and Group II: CE. Following features were compared: demography, clinical picture, postoperative morbimortality, outcome and survival. RESULTS: Thirty-four adult patients were analyzed. There were 82% (28) females and 18% (6) males. The age average was 33.58 years (13-84). Seventy percent (30) were "choledochal cyst". Eighty percent (27) were surgically handled: 52% (14) with CRR-en-Y (Group I) versus 58% (13) with CE (Group II). Both groups were comparable. Without operative mortality and low postoperative morbidity in both, CE had more long-term complications: In this group 70% (9) were readmitted: and 7 underwent reoperation. Mean follow-up was 35 months (6-132) versus 152 months (12-408) respectively. CONCLUSIONS: CRR-en-Y is the standard treatment of CDBS in the adult patient.
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Anastomose em-Y de Roux/métodos , Cisto do Colédoco/cirurgia , Coledocostomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Duodenostomia , Feminino , Humanos , Jejunostomia , Fígado/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BALB/c mice with pulmonary tuberculosis develop a T helper cell type 1 response that peaks at 3 weeks, temporarily controlling bacterial growth. Then bacterial proliferation recommences, accompanied by increasing interleukin (IL)-4 levels and decreasing interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, and inducible nitric oxide synthase (iNOS) levels. These changes mimic those in the human disease. In a previous study, administration of dehydroepiandrosterone (DHEA) beginning on day 60 after infection reversed these changes and protected the mice. However, DHEA is suboptimal for human use, partly because it is readily metabolized into sex steroids. 16alpha-Bromoepiandrosterone (EpiBr; 16alpha -bromo-5alpha -androstan-3beta-ol-17-one) is a synthetic adrenal steroid derivative that does not enter sex steroid pathways. In the present study, when tuberculous BALB/c mice were treated with EpiBr 3 times/week beginning on day 60, inhibition of bacterial proliferation and increased expression of TNF-alpha, IFN-gamma, and iNOS were observed, although decreased expression of IL-4 was also observed. Moreover, when given as an adjunct to conventional chemotherapy, EpiBr enhanced bacterial clearance. Trials for the use of EpiBr in the treatment of human tuberculosis are now justified.
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Adjuvantes Imunológicos/farmacologia , Androsterona/análogos & derivados , Androsterona/farmacologia , Quimioterapia Adjuvante , Células Th1/efeitos dos fármacos , Tuberculose Pulmonar/imunologia , Adjuvantes Imunológicos/farmacocinética , Adjuvantes Imunológicos/urina , Animais , Ativação Linfocitária/efeitos dos fármacos , Camundongos , Camundongos Endogâmicos BALB C , Mycobacterium tuberculosis/imunologia , Células Th1/imunologia , Tuberculose Pulmonar/metabolismo , Tuberculose Pulmonar/patologia , Fator de Necrose Tumoral alfa/imunologiaRESUMO
BACKGROUND/AIMS: Non-cirrhotic portal hypertension has a better prognosis than other forms of portal hypertension because of a well-preserved liver function in most cases. These patients are good candidates to receive surgical treatment, which is the therapeutic choice available with the lowest rebleeding rate. Because of abnormalities in the splanchnic vessels due to the nature of the diseases, many of them cannot be shunted. An extensive esophagogastric devascularization, the complete portoazygos disconnection, was evaluated. METHODOLOGY: A retrospective review of files of 31 patients, among 491 operations between 1991 an 2001 was carried out in a tertiary care Academic University Hospital. Patients comprised those with non-cirrhotic bleeding portal hypertension treated by means of complete portoazygos disconnection. Extensive two-stage (thoracic and abdominal) esophagogastric devascularization with modified transection of the esophagus was performed. MAIN OUTCOME MEASURES: recurrence of hemorrhage, encephalopathy and survival. RESULTS: Thirty-one patients were treated. In 17 cases (54%) a hypercoagulable state was demonstrated. No operative mortality was observed (0-30 days) with a total of 62 operations (two stages per patient). No case of encephalopathy was observed and in 3 cases (9%) rebleeding was recorded. The survival curve showed a 5-year survival of 97% and a 10-year survival of 93%. CONCLUSIONS: Complete portoazygos disconnection is an excellent surgical alternative for patients with non-cirrhotic portal hypertension, with a low morbidity and mortality as well as a low rebleeding rate and good long-term survival.
Assuntos
Hemorragia Gastrointestinal/patologia , Hemorragia Gastrointestinal/cirurgia , Hipertensão Portal/patologia , Hipertensão Portal/cirurgia , Adulto , Biópsia por Agulha , Feminino , Seguimentos , Hemorragia Gastrointestinal/mortalidade , Humanos , Hipertensão Portal/mortalidade , Imuno-Histoquímica , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Medição de Risco , Estudos de Amostragem , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
OBJECTIVE: Bile duct injuries have a frequency of 0.1% to 0.3% even in the most experienced centers. Complex biliary lesions usually require a bilioenteric anastomosis, achieving good long-term results in 80% to 90% of the cases. Besides injuries to the abdominal contents during laparoscopy (by trocars or electrocautery), intestinal complications associated with reconstruction attempts can be observed. We analyzed the concomitant intestinal complications in 251 patients with iatrogenic biliary injuries reconstructed over this 12-year period. METHODS: A retrospective review of patients with biliary tract reconstruction after iatrogenic injury in a tertiary academic health-care center was done. All patients with concomitant intestinal injury were included; type of operation and postoperative outcome were analyzed. RESULTS: Among 251 patients, 35 cases had a concomitant intestinal injury. The most common site of fistulization was the duodenum (18 cases, 50%); 9 cases were associated with long-term subhepatic drains (more than three weeks), and the other 9 cases were associated with a dehiscent hepatoduodenostomy. Faulty Roux-en-Y reconstruction was observed in 5 cases. In 5 cases, fistulization of the jejunum and ileum, secondary to drain placement, was documented, as well as 3 cases with colonic injuries. Two patients had a dehisced Roux-en-Y anastomosis. One had a bilioenteric omega type ileal anastomosis, and 1 had a hepatoileal anastomosis without omega reconstruction. Primary repair of the duodenum with resection of the affected intestinal or colonic segment was done at the same time of biliary repair without related morbidity. CONCLUSIONS: Concomitant gastrointestinal injures were found with an incidence of 15% in our series. The most common site of fistulization is the duodenum. In half of the patients, it was secondary to a dehiscent hepatoduodenostomy, whereas in the other, it was caused by long-term subhepatic drains. Besides faulty Roux-en-Y reconstruction, fistulization was related with long-term drains. Primary repair and resection of the affected segment of jejunum, ileum, and colon can be done during the same operative stage of biliary reconstruction, without significant correlated mortality.
Assuntos
Doenças dos Ductos Biliares/etiologia , Ductos Biliares/lesões , Endoscopia do Sistema Digestório/efeitos adversos , Doença Iatrogênica , Intestinos/lesões , Centros Médicos Acadêmicos , Adulto , Idoso , Anastomose em-Y de Roux , Doenças dos Ductos Biliares/mortalidade , Doenças dos Ductos Biliares/cirurgia , Ductos Biliares/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Endoscopia do Sistema Digestório/métodos , Endoscopia do Sistema Digestório/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Enteropatias/etiologia , Enteropatias/mortalidade , Enteropatias/cirurgia , Intestinos/cirurgia , Complicações Intraoperatórias/cirurgia , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Medição de Risco , Taxa de SobrevidaRESUMO
Portal biliopathy is a rare condition that is usually not diagnosed. It is associated with presence of varix around bile duct with concomitant ischemic damage and structural alterations of bile duct wall; this produces obstructive phenomena. There are scarce reports on the literature this entity. In the present paper, we report two cases in which obstruction of extrahepatic bile duct was associated with cholecystitis with well-documented extrahepatic portal hypertension. Both cases were managed with cholecystectomy and endoscopic placement of endoprothesis. Treatment of portal biliopathy should be adjusted to the individual patient's characteristics. It is focused on the one hand on management of portal hypertension and on the other hand to management of obstructive jaundice. When cholecistitis is found, cholecistectomy should to be performed. If the patient develops concomitant gastrointestinal bleeding due to portal hypertension, management of the problem could require surgical devascularization, shunting procedures, or endoscopic variceal ligature.