[Hemangiopericytoma: report of 4 cases]

Hemangiopericytoma is an infrequent tumor of vascular origin derived from Zimmermann's pericyte cells. It is generally seen in adults of both sexes and its major risk is late recurrence, that occurs in up to 50% of cases. Its spread pattern is principally hematogenous. The management of the disease is similar to that of other sarcomas. Surgical treatment alone controls the disease in less than 30% of cases and the association of surgery and radiation therapy decrease the risk of local and distant recurrence. We report four cases of hemangiopericytomas, located in the prostate, retroperitoneum, supraclavicular space and lung. The four patients were treated with surgery and radiation therapy, three of them have had no evidence of recurrence after 1.5 to 6 years of follow up and the patient with the tumor located in the lung died one year after the operation.

[Colorectal cancer. Study of survival and surgical results]

The aim of this study was to assess the progress in the surgical treatment of colorectal carcinoma in a 15 years period at the Catholic University Clinical Hospital. The medical records of 397 patients were retrospectively analyzed. Two hundred eighty four patients (164 male) aged 24 to 90 years old, subjected to elective and curative interventions, were selected for the study and separated in two groups: 132 subjects operated between 1975 and 1984 (group A) and 152 operated between 1985 and 1989 (group B). Group B patients were older (66.7 vs 61.3 years old), had a higher proportion of Dukes A tumors (11 vs 18%) and a lower proportion of lesions localized in the rectum (37 vs 49%). Rectal operations had higher morbidity than colonic interventions (35 vs 17.5%). Operative mortality was 0.7% in group A and 0.6% in group B. Ninety one percent of patients had a mean follow up of 38 months. Five years actuarial survival was 52% in group A and 69% in group B and 58, 74 and 46% for tumors Dukes A, B and C respectively.

[The effectiveness of endoscopic retrograde cholangiopancreatography in the etiological diagnosis of postcholecystectomy syndrome]

A retrospective study of 249 with symptoms and signs of postcholecystectomy syndrome was made to evaluate the usefulness of endoscopic retrograde cholangiopancreatography (ER CP) in its etiological diagnosis. From 1693 ERCP evaluated, 1108 were checked and from these 249 patients showed symptoms and signs after the cholecystectomy. So they were selected to practice a diagnostic ERCP. 204 patients were females and its principal symptom was jaundice. Lesions found in most of the cases were: stones in the bile ducts (45.78%), benign biliary stenosis (8.3%), stenosis of vater's papilla (7.22%) and biliary fistula (7.22%). It can be conclude that biliary stones is the most frequent pathology in those patients with clinical suspicion of biliary-pancreatic organicity and that ERCP is the principal method of diagnosis in these patients.

[Budd-Chiari syndrome. Report of 2 surgical cases]

Two female patients with Budd-Chiari syndrome and suffering of Polycythemia Vera are reported. Both patients were operated performing a central spleno renal shunt with preservation of the spleen and ligation of the splenic artery. The patients are well 6 and 24 months after the operation respectively. The principal features and therapeutic alternatives of this condition are reviewed briefly.

[Disseminated histoplasmosis in a patient with acquired immunodeficiency syndrome]

A twenty nine year old male homosexual presented with malaise, weight loss, fever and profuse sweating. An ill defined abdominal mass was found during physical examination in the right lower quadrant and chest X rays disclosed a pleural effusion. HIV antibodies and hepatitis B surface antigen were positive and immunological parameters were altered. Light and electron microscopic examination of operative biopsies of the abdominal mass revealed the presence of Histoplasma capsulatum. Treatment with Amphotericin B was started with a favorable response and the patient was discharged. He was readmitted with a septic shock and died. Necropsy showed pulmonary histoplasmosis. This is the first case of disseminated histoplasmosis in a patient with AIDS described in Chile.

[Respiratory complications in severe acute pancreatitis]

Respiratory complications are important causes of mortality in severe acute pancreatitis. We analyzed the pleuropulmonary complications that occurred in a series f 63 patients with severe acute pancreatitis. The most frequent were respiratory failure (52.4%) and bronchopulmonary infection (33.3%), both associated with sepsis and a high mortality rate. The initial laboratory workup included serial arterial blood gases and chest roentgenogram within the first 24 hours. The latter was useful to predict mortality. The tracheobronchial cultures isolated only enteral bacteriae. We conclude that pleuropulmonary complications are clearly related to the outcome of severe acute pancreatitis, specially when associated to sepsis.

[Acalculous acute cholecystitis caused by Cryptosporidium in a patient with AIDS]

We report a patient with the acquired immunodeficiency syndrome who developed acute cholecystitis. Removal of the gallbladder revealed infection by Cryptosporidium spp. The clinical course after cholecystectomy was favourable. The pathogenesis and therapy of this complication in patients with AIDS is discussed.

[Treatment of non-variceal upper digestive hemorrhage with endoscopic thermocoagulation]

Over a year period, 60 of 172 patients presenting with upper gastrointestinal bleeding were treated by endoscopic thermocoagulation. Entry criteria included active bleeding (pulsatile or oozing), a visible vessel, sentinel clot or the presence of a pigmented protuberance at the ulcer crater. Hemostatic therapy was performed using the heat probe. The physical status and risk of the patients was estimated according to the ASA classification. Hemostasis was obtained in 17 of 21 patients with pulsatile bleeding (81%), 30 of 30 patients with oozing (100%) and 18 of 18 patients with a visible vessel or a pigmented protuberance in the lesion (100%). Three patients, older than 70 years of age, died. All had pulsatile bleeding from a deep ulcer located at the posterior-inferior wall of the duodenal bulb. They were classified as ASA III (n = 1) or IV (n = 2) with significant concomitant illness. These results suggest that endoscopic thermocoagulation is an effective treatment of active upper gastrointestinal bleeding, especially useful in a group of high risk patients.

[Duodenal villous adenoma. Report of 2 cases]

The case history, diagnosis and management of 2 pts with villous adenoma of the duodenum are reported. Both were operated on with good results, with no relapse at 12 and 18 months of observation. This tumor which is more frequently located in the vicinity of the Vater Ampullae, has a low incidence. One third of them have malignant elements raising an issue on therapeutic options. Literature is reviewed with special emphasis on the type of surgical resection to be used.

[Incipient and intermediate gastric cancer II. Anatomo-pathological and surgical aspects. Cooperative study in 13 hospitals]

Anatomic and surgical characteristics of 233 pts with early, and 120 with intermediate gastric cancer, from 13 hospitals in Chile are analyzed. 63% had depressed or excavated lesions. Most of the tumors were located in the inferior or middle third, while only 17% of the early carcinomas were found in the superior third of the stomach, specially in the lesser curvature. 5% had residual tumor in the gastric remanent. Histologically, tubular adenocarcinoma was the most common finding. According to Lauren's classification intestinal carcinoma was more frequent than the diffuse type. Surgeons underestimated lymphatic node involvement (macroscopic appreciation) in up to 58% of the cases when compared to the pathologists observation (microscopic appreciation). This was specially true in muscular carcinomas. The incidence of lymphatic metastases was 6% in mucous, 12% in submucous and 57% in muscular carcinoma. The need of complete lymph node dissection of all the lymphatic barriers is emphasized.

Malignant papillomatosis of the common bile duct. A case diagnosed by endoscopic retrograde cholangiopancreatography

Bile duct papillomatosis is a rare entity with a high risk of malignant change. We report the case of a 60-year-old man with malignant papillomatosis of the distal common bile duct and a separate carcinoma of ampulla of Vater. The patient had previously undergone surgery for acute cholecystitis and common bile duct calculi. Three months later the patient developed jaundice and fever. An endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects adherent to the wall of the distal common bile duct. Pancreatoduodenectomy was performed with complete resection of the extrahepatic bile duct. Histologic examination showed a multicentric papillary adenocarcinoma of the common bile duct associated with an adenocarcinoma of the ampulla of Vater. The resection margins were free of tumor.

[Acute severe pancreatitis. Analysis of mortality and morbidity]

Sixty-three patients with severe acute pancreatitis have been studied. Pancreatitis was associated with biliary tract disease in 23 patients (36.5%) and with alcoholism in 21 (33.3%). It occurred post-operatively in 9, and was associated with other conditions in 10. We evaluated the Ranson prognostic signs (RPS) with the appearance of complications. 36 patients (57.2%) had 3-4 RPS, 9 (30.2%) had 5-6 RPS and 8 (12.6%) had 7 or more RPS. Diagnostic laparotomy was performed in 11 patients (17.5%). 55 patients were operated one or more times due to failure of medical treatment and/or local and septic complications. The most frequent complications were pancreatic abscess (60.3%), sepsis (58.7%) and pulmonary insufficiency (52.4%). Renal failure occurred in 26 patients and 9 required dialysis. Of the patients with renal failure, 84.6% (22/26) had 4 or more RPS; 78.4% (29/37) of those with sepsis and 71.6% (27/38) of those with pancreatic abscess also had 4 or more RPS. The mean duration of hospitalization of survivors was 58 +/- 30 days. Overall mortality was 28.6%. We conclude that RPS are helpful to predict complications in patients with severe pancreatitis.

[Regeneration of gastric mucosa after endoscopic biopsy]

Eleven gastric mucosal defects produced by endoscopic biopsy in non-tumoral areas were histologically studied in gastrectomy specimens. The biopsies had been performed from one up to seven days before the operation. The base of each defect was formed by submucosa infiltrated by erythrocytes, fibrin and neutrophils, which were later replaced by small blood vessels, fibroblasts and collagen fibrils. The mucosa of the margins bowed down towards the base of the defect. This marginal mucosa showed dedifferentiation of the glandular epithelial cells, increased mitotic index and some cystic glandular structures lined by basophilic cells. The defect was progressively covered by a layer of flattened or cuboidal cells in which no mitoses were observed; their cytoplasm contained mucosubstances similar to those of the superficial epithelium of the remaining mucosa, either foveolar- or intestinal metaplastic-type. From this layer, simple gland-like invaginations to the underlying connective tissue were observed. The findings are consistent with the regenerative events described in experimental gastric ulcers in animals. The method employed may be useful to study specific aspects on the regeneration of the human gastric mucosa.

[Sudden unexpected nocturnal death: report of a case and review of the literature]

Sudden death usually affects individuals with severe heart disease. A more dramatic phenomenon is the sudden unexpected death of individuals with no evidence of heart disease. It has been described mainly in young healthy males under severe stress. We present a 32 year old man who presented ventricular fibrillation during sleep and was resuscitated by his wife. Recurrent episodes of VF occurred in the following hours. The study, including coronary angiography, revealed a normal heart. Endomyocardial biopsy showed minimal alterations with scarce areas of atrophy and fibrosis. Electrophysiologic evaluation showed an extremely short refractory period of the right ventricle, but the arrhythmia could not be induced by electrical stimulation. An internal cardioverter defibrillator was implanted since the risk of recurrent VF was high. A review of the literature concerning this unusual entity is offered.

[The medical treatment of intestinal obstruction due to adhesions and adherences]

Adhesions are the most common cause of intestinal obstruction. Medical treatment for those patients with no signs of vascular involvement has been successful in many cases. We reviewed the clinical records of 87 patients with intestinal obstruction due to adhesions, having a total of 122 episodes. Satisfactory follow up was obtained in 76% of patients for a mean of 29.6 months. 47% of episodes resolved without need for surgical intervention. Volume entrapment during the first hours was correlated with need for surgical treatment (p < 0.01). Recurrences were not different between medical and surgical patients (p = 0.28). Thus, medical treatment of this type of intestinal obstruction may be attempted in most patients, not only those who are poor surgical risks.

Catabolism of chylomicron remnants in patients with previous acute pancreatitis

A recent study reports that patients with previous acute pancreatitis commonly have an abnormal clearance of serum triglycerides after an oral fat load. This observation supports the hypothesis that patients with previous acute pancreatitis and normal fasting serum triglyceride levels may have a preexistent abnormality in the metabolism of chylomicrons. To test this hypothesis, the catabolism of chylomicrons and their remnants was studied in a series of 7 patients who had sustained an attack of pancreatitis (2, gallstone related; 2, alcohol ingestion; 1, hydatid cyst; and 3, no associated pathological condition) at least 18 mo earlier. All the patients had previously had abnormal oral-fat tolerance test results. These patients were compared with a series of 6 healthy volunteers. Chylomicrons were endogenously labeled with an oral dose of retinyl palmitate, and their plasma elimination half-life was calculated. The retinyl palmitate absorption rate constants were similar in control and pancreatitis patients. The chylomicron t1/2 were 2.3 +/- 0.8 (SD) h and 3.9 +/- 1.8 h in the control and pancreatitis groups, respectively (p = 0.07). The chylomicron remnant t1/2 was 2.7 +/- 1.1 h in the control group and 5.2 +/- 2.4 h in the pancreatitis group (p less than 0.05). This study supports the hypothesis that subjects with previous acute pancreatitis may have an abnormality in the catabolism of chylomicron particles. This abnormality may represent a preexistent genetic condition expressed in either the apoprotein composition of chylomicrons or in the hepatic apolipoprotein E-receptor activity.

[Abdominal actinomycosis: review apropos of 3 cases]

Actinomycosis is a chronic bacterial infectious disease, characterized by multiple abscesses, draining sinuses and abundant dense fibrous tissue. The intra-abdominal variety is rarely found and difficult to diagnose. We report three cases of intra-abdominal actinomycosis successfully treated by surgery and by longterm antibiotic therapy. One patient had a liver actinomycosis and two had ileo-caecal disease. Pertinent literature is reviewed.

[Duodenal obstruction caused by cholelithiasis (Bouverets' syndrome): a clinical case]

A 55 year old man presented with vomiting, abdominal pain, diarrhea, jaundice and choluria. An obstruction of the gastric outlet by a large gallstone located at the duodenum was demonstrated by radiologic, ultrasonographic and endoscopic examinations. The stone could not be removed through endoscopy and the patient was successfully operated on. A review of published reports is included.

[Gastric cancer: surgical results and survival]

From 1975 to 1984, 292 patients with gastric cancer were treated according to a prospective and standardized surgical protocol. This series included 195 men and 97 women, with an average age of 62.5 +/- 11 years (SD). In 20 patients (6.8%) surgery was not performed and 99 were considered unresectable at laparotomy. Gastric resection was performed in 173 (63.3%) (distal subtotal gastrectomy in 94 and total gastrectomy in 79). Operative mortality for subtotal gastrectomy was 3.1% and 6.3% for total gastrectomy. Early gastric cancer was found in 21 patients (none presented lymph node metastases). The cancer invaded the muscular layer in 18 (31% with lymph node metastases) and reached beyond the muscular layer in 134 patients (60.8% with lymph node metastases). The five year actuarial survival was 0% in patients who did not undergo gastric resection, 35.5% for those patients with tumor invading the serosal layer or beyond who were resected, 56.5% for those with invasion up to the muscular layer and 91.8% for patients with early gastric cancer. For those patients who underwent a curative resection, actuarial five year survival was 81%.

[Value of preoperative colonoscopy in colon-rectal neoplasms]

The surgical approach to treat colo-rectal carcinoma is usually based on the findings of barium enema. In 102 patients we reviewed the yield of pre-operative colonoscopy. Barium enema revealed the cancer in 76 of 84 patients (91%), whereas colonoscopy did so in 96 of 102 subjects (94%). In addition, 5 associated cancerous lesions were demonstrated by colonoscopy and none by barium enema. Associated benign lesions were seen in 14 patients. In 5 patients the surgical plan based on the barium enema was modified by the findings at colonoscopy. Eight false negatives to barium enema were correctly diagnosed by colonoscopy. We conclude that colonoscopy yields valuable information, beyond that of barium enema, in patients with colo-rectal cancer.

[Mesenteric vascular insufficiency caused by chronic occlusive disease: experience with the surgical management of 9 cases]

We report our experience in the surgical treatment of visceral arterial occlusive disease in 9 patients. The etiology was atherosclerosis in 7 cases and arteritis in 2. Four patients were admitted because of acute mesenteric ischemia, but only two had a previous history of intestinal angina. Four consulted because of chronic mesenteric angina and only 1 asymptomatic patient received prophylactic revascularization. The clinical picture of postprandial abdominal pain, weight loss, bowel habit disturbance, abdominal bruit or signs of occlusive disease elsewhere, should lead to clinical diagnosis. Angiographic evaluation is mandatory to plan the best surgical approach. In this series we revascularized 14 vessels in 9 patients using different technics. Two patients died (42 and 90 days) following revascularization and partial resection of the gut for extensive infarction. All survivors achieved symptom relief and or recovered or stabilized their weight.

[Colorectal cancer: follow-up after curative resection]

From Jan 1978 to Dec 1984, 128 patients had a curative resection of colorectal carcinoma. A program for early detection and surgical correction of recurrences was initiated in 88 patients with a mean age of 61 years (range 24 to 85). Seventy two patients complied with the program involving clinical examination, chest X-ray, alkaline phosphatase and CEA determinations and endoscopy at 6 month intervals. Mean follow up was 36 months (range 6 to 60). A total of 28 recurrences (32%) were detected: 4 local, 17 distant and 7 local and distant. Recurrences occurred in 46% of grade C, 19% of grade B and 0% of grade A lesions. Sixty eight% of recurrences were detected within 12 months and 93% within 36 months after surgery. Recurrences were detected by clinical examination in 71% of cases. CEA determination was sensitive (81% and specific (92%) for detection of recurrences in the remaining patients. Four patients (14%) were reoperated on with a survival of 3 to 26 months, all dying from disseminated disease. We conclude that this program did not help to improve the 5 year survival rate of colorectal carcinoma submitted to curative resection. CEA determination may be indicated at 2 month intervals during the period of increased recurrence risk.

[Acute pancreatitis and hypertriglyceridemia]

The etiology and pathogenesis of acute pancreatitis are unknown in the majority of patients. However, it is well known that there are several relevant clinical conditions associated to acute pancreatitis such as, gallstone disease, alcoholism and hypertriglyceridemia. The possible pathogenic relationships between acute pancreatitis and hypertriglyceridemia are discussed in this article. It has recently been shown that a significant proportion of patients with a history of acute pancreatitis have an abnormal clearance of exogenous triglycerides, indicating the presence of a preexistent metabolic abnormality in this population. This observation supports the hypothesis of a possible genetic heterogeneity related to either an abnormal apoprotein profile of chylomicrons, or hepatic receptor mechanism of chylomicron remnants uptake in the liver. If this hypothesis proves to be correct, then a genetic marker may be available to identify the subjects at high risk for acute pancreatitis.