Revista paulista de medicina最新文献

Rupture of the diaphragm from blunt trauma is uncommon, but greatly improved prehospital care and transportation of victims has increased the frequency at which patients who sustain this injury arrive at the emergency room alive. We report a case of bilateral diaphragmatic rupture from blunt abdominal trauma in a 33-year old man. Diagnosis was established by laparoscopy after suggestive chest X-rays, liver scintigraphy, CT scan and magnetic resonance imaging. The methods used to diagnose this condition are analyzed.

Transitional cell carcinoma (TCC) of the bladder is a neoplasm with variability in its clinical behavior. Although there are several studies correlating stage and ABO isoantigen expression with invasiveness, there is no single predictor factor to assess the potential invasiveness, especially in the low grade, non-invasive TCC. In the present study we evaluated the correlation of histological grade plus stage and the expression of beta human chorionic gonadotropin (beta-hCG), in 100 cases of TCC, with the clinical behavior. These features were correlated with tumor progression in patients with at least two years of follow up. We observed more aggressiveness in G4 group (high grade and invasive) (93% had tumor progression) when compared to G1 group (low grade and superficial) (11% had tumor progression). However in 25.5% of the TCC cases (groups G2: low grade and invasive and G3: high grade and superficial) the clinical behavior was intermediate, showing some limitation in using grading and staging only, as a predictive factor. There was an expression of beta-hCG in 21.4% of the cases in up to 25% of the tumor cells without any trophoblastic morphology. These beta-hCG producing TCC had a strong correlation with aggressiveness: 39.1% and 12.8% of the TCC expressed beta-hCG with and without tumor progression, respectively.

Since last decade, myocutaneous flaps have appeared among the most versatile and safest options for the reconstruction of defects caused by large oncological resections, in the head and neck area. Undoubtedly, the myocutaneous flap of the pectoralis major muscle is the most widespread and accepted, due to the long experience obtained through its use. Nevertheless, it presents some restrictions related not only to its rotation arch, but also to the esthetic consequences for the donor site in females. Over the last years, there has been a growing interest in the posterior trapezius myocutaneous flap (PTMF), which proved to be a valuable alternative for reconstruction in selected cases. The experience of the Department of Head and Neck Surgery, at the University of São Paulo Medical School-Hospital das Clínicas, using this technique, is reported here in a detailed description.

A retrospective study of 40 hysterectomies due to hemorrhage performed at the "Hospital das Clínicas, Faculdade de Medicina de São Paulo", from January 1978 to August 1989 was conducted in order to determine which type of hysterectomy (total or subtotal) is better indicated during the pregnant-puerperal period. We analyzed operating time, quantity of blood derivatives transfused during the intra- and postoperative periods, time of postoperative hospitalization, number of intra- and postoperative complications, and deaths. The results did not show statistically significant differences between the two types of hysterectomy. We conclude that total hysterectomy is preferable in any clinical situation, especially in the presence of uterine atony and low implanted placenta.

In this preliminary note the authors describe a new technique consisting in the use of videoscopy as an aid in surgery for the placement of tissue expanders in a patient with sequelae due to burn scarring on the posterior thorax. The surgical steps are described, together with the technical details of the use of the videolaparoscopy equipment. The authors discuss the advantages of this new technique which permits the use of small routes of approach, perpendicular to the expansion area, thus, providing an excellent view with a minimal amount of trauma. The method prevents complications such as dehiscence with prosthesis exposure and hematomas. A precise dissection of the necessary area can be achieved by this technique, a process facilitated by the continuous expansion and bulging of the dissected area obtained by controlled injection of carbon dioxide. The disadvantages are the high cost of the procedure and the long surgical time. The authors emphasize the need for future rationalization of the indications and for an appropriate methodology for the procedure.

The authors report the results obtained from peripheral nerve crushing in the treatment of ischemic rest pain and/or trophic lesions of toes and feet. They studied retrospectively 102 patients who were submitted to peripheral nerve crushing at the "Hospital das Clínicas da Universidade de São Paulo" during a sixteen-year period, from March 1971 to April 1987. These patients had no other choice, either clinical or surgical. The results were evaluated under three aspects: elimination of pain, evolution of trophic lesions and postoperative complications. The follow-up period varied from 1 month to 6 years (mean of 18 months). The results showed immediate elimination of pain in 94% of the patients. The remaining 6% were reoperated on within 24 to 48 hours, due to technical failure in identifying some of the nerves during the first operation. Regarding the trophic lesions, in 71% of the patients the results were good and the remaining underwent amputation at leg or thigh. The worst results were obtained in patients with necrotic lesions (p < 0.05). Three patients presented surgical wound dehiscence. The authors conclude that peripheral nerve crushing constitutes a valid alternative for a select group of patients with uncontrollable ischemic rest pain in the feet.

The prognostic value of 16 parameters was evaluated in a series of 126 squamous cell carcinoma of hypopharynx between 1978 and 1985 at the "Serviço de Cirurgia de Cabeça e Pescoço" of the "Hospital Heliópolis", São Paulo. The variables considered were: age, sex, ethnic background, interval between diagnosis and detection of first symptom, extension of primary lesion (T), N categories, histologic evaluation of primary lesion (pT) and neck node metastasis (pN), number of clinical positive nodes (NGPOS), radiation, chemotherapy and recurrence of the disease (local, regional and distant metastasis). After a multifactorial study using Cox life table model (3) and Dixon mathematic-statistical model (8), 5 of those 16 parameters were found to influence survival, independently. The five variables organized according to hypopharynx cancer prognostic significance were: age, odynophagia, number of clinical (NGPRE) and histological (NGPOS) metastatic lymph nodes and radiation therapy; odynophagia and radiotherapy were the variables that decreased the relative risk of recurrence in the survival of cancer of the hypopharynx.