OBJETIVO: Analisar os resultados do tratamento cirúrgico das formas necrosantes, ou graves, da pancreatite aguda e da forma crônica agudizada. MÉTODO: Foi preenchido um protocolo, de modo consecutivo e prospectivo, de 68 pacientes operados por pancreatite aguda grave e crônica agudizada, no período de 1982 a 2000. Os pacientes foram classificados em três categorias: 1. Pancreatite aguda biliar; 2. Pancreatite aguda de causa indeterminada; 3. Pancreatite crônica agudizada. RESULTADOS: As indicações para o tratamento cirúrgico foram: diagnóstico incerto (32,3%); necrose infectada (60,3%) e para necrosectomia (7,4%). As operações realizadas foram: desbridamento de necrose infectada(70,6%); operações sobre as vias biliares (20,6%) e desbridamento de grandes necroses (7,4%). Os óbitos hospitalares incidentes, por categoria foram: 1. Pancreatite aguda biliar (33,3%); 2. Pancreatite aguda indeterminada (45,0%); 3. Pancreatite crônica agudizada (37,0%). A média de óbitos foi de 38,2%. Vinte e cinco pacientes foram reoperados, uma ou várias vezes, e nestes a mortalidade foi de 40,0%. Os abscessos foram responsáveis por 52,0% dos óbitos e as outras complicações que resultaram em óbitos, sempre evoluiram para infecção. CONCLUSÕES: Ocorreu um alto índice de operações por diagnóstico incerto. Esta indicação deve se restringir aos casos onde não seja possível o diagnóstico diferencial com certas causas de abdome agudo. As indicações para tratar precocemente a litíase biliar devem ser evitadas ou reduzidas a situações específicas. As reoperações são freqüentemente indicadas nesses pacientes e a infecção foi a principal causa de morte.

BACKGROUND: To evaluate the results of surgical treatment of acute necrotizing pancreatitis, as well as its necrotizing alcoholic form. METHODS: Patients were analyzed according to a prospective protocol. Surgery was performed on 68 patients due to necrotizing acute pancreatitis and acutized chronic pancreatitis from years 1982 to 2000. Patients were grouped into three categories: 1) Biliary acute pancreatitis; 2) Acute pancreatitis of unknown etiology; 3) Necrotizing alcoholic pancreatitis. RESULTS: Patients had the following clinical indications for laparotomy: 1) Uncertain diagnosis (32.3%); 2) Infected necrosis (60.3%); 3) Necrosectomy (7.4%). The surgical findings were: Infected necrosis (70.6%); biliary complicatios (20.6%) and large necrosis 1(7.4%). Global hospital mortality was 38.2%. Individual categories showed a mortality of 33.3% (biliary acute pancreatitis), 45.0% (undetermined acute pancreatitis) and 37.0% (necrotizing alcoholic pancreatitis). Reoperations were indicated once or more times in 25 patients, and among these, the mortality was 40%. Abscesses were the main cause of death (52.0%), and all the other complications that resulted in death invariably evolved to infection. CONCLUSIONS: The indications of early surgical treatment for gallbladder stones, as well as when the diagnosis is not clear, should be reduced to very specific circumstances. Reoperations are common in these patients and infection was the main immediate cause of death.

OBJETIVO: Analisar as indicações, técnicas e resultados do tratamento cirúrgico de 74 pacientes operados por complicações da pancreatite crônica. MÉTODO: Foram pacientes consecutivos, estudados prospectivamente pelo preenchimento de um protocolo individual, no período de 1971 a 2000. Foram realizadas cirurgias de derivação e ressecção. O acompanhamento foi feito pelo agendamento de consultas no ambulatório, por convocação por cartas e telefonemas. RESULTADOS: Dos 270 pacientes com pancreatite crônica, acompanhados pelo Serviço, 74 (27,4%) foram operados. Destes 74 pacientes, 97,7% eram do sexo masculino e a idade variou de 15 a 63 anos, com média de 39,4 anos para alcoolistas e 33,1 para aqueles com outras etiologias. O alcoolismo foi a causa da doença em 68 pacientes (90,5%) e os outros casos estiveram relacionados a hiperparatiroidismo(1), pancreatite hereditária (1), fibrose retroperitoneal (1) e em três casos a etiologia não foi definida. As seguintes causas únicas ou associadas definiram a indicação cirúrgica:1. dor em 44,6% dos pacientes; 2. compressão de vias biliares em 28,4%; 3. pseudocistos em 12,2%; 4. fístulas internas em 10,8%. Cinqüenta pacientes (67,5%) foram submetidos a operações de derivação e 24 (32,5%) a cirurgias de ressecção. Oito pacientes derivados (16,0%) complicaram, ocorrendo três óbitos; dez ressecados (41,6%) complicaram, com cinco óbitos. Os óbitos estiveram relacionados a abscessos, às deiscências e às hemorragias cirúrgicas. CONCLUSÕES: As cirurgias de derivação mostraram-se mais seguras e as complicações que evoluíram com infecção foram as mais graves e ocorreram com mais freqüência nas ressecções.

BACKGROUND: To evaluate the indications, methods and results of the surgical treatment of 74 patients operated on for chronic pancreatitis complications. METHOD: Consecutive patients' charts were studied prospectively, during the years of 1971 to 2000. Surgery was indicated for pain, billiary tract stricture, pseudocysts, pancreatic ascitis and pancreaticopleural fistulas. Pancreaticojejunal anastomosis, billiary tract derivations and resections were performed. Follow-up was achieved through ambulatorial appointments or by mail and telephone calls. RESULTS: Of 270 patients listed with chronic pancreatitis, 74 (27.4%) were operated on. 97.7% of them were males. Patients varied in age from 15 to 63 years old, with an average of 39.4 years for alchoolists and 33.1years for those with pancreatitis of other etiologies. The disease was caused by alchool in 68 patients (90.5%). The other causes were: hyperparathyroidism (1), hereditary pancratitis (1), retroperitoneal fibrosis(1) and in three patients the etiology was unknown. Indications for surgery were: 1. Pain in 44.6% of the patients; 2. Billiary tract stricture (28.4%); 3.Pseudocysts (12.2%); 4. Pancreatic ascitis and pancreaticopleural fistulas (10.8%). Derivations were performed in 50 patients (67.5%), and resections in 24 (32.5%). Complications ocurred in eight patients with five hospital deaths related to abscesses, suture leaking and surgical bleeding. CONCLUSIONS: There was less morbidity and mortality for derivations and than after resections.

The authors report the surgical procedure in two patients with pseudomyxoma peritonei, histologically considered as mucinous adenocarcinoma. In both patients, intestinal loops and other visceras were blocked and it was not possible to localize the tumor's origin. There was, in both cases, a great volume of mucinous ascitis. In the first patient a laparotomy was performed and a drainage by a five centimeters peritoneostomy in the abdominal upper left quadrant. In the second just a peritoneostomy was performed in the same location. The sequential irrigation of the abdominal cavity controlled the ascitis in a few days. Certainly this approach avoided a second procedure to clean the mucinous ascitis.

OBJETIVO: O propósito do presente estudo é analisar as dificuldades quanto ao diagnóstico, avaliação prognóstica e conduta em sete pacientes portadores de tumores neuroendócrinos do pâncreas (apudomas), estudados na última década, comparando os resultados com aqueles discutidos na literatura. MÉTODO: A idade dos pacientes variou de 15 a 66 anos, com média de 38,4 anos. Todos foram submetidos a alguma forma de ressecção pancreática por tumores neuroendócrinos. Os exames histológicos foram feitos pelas técnicas tradicionais e por imuno-histoquímica. RESULTADOS: Três pacientes tiveram um diagnóstico inespecífico de tumor neuroendócrino; dois de vipoma e dois de gastrinoma. As síndromes não se manifestaram claramente, ainda que cada caso tenha tido um rótulo diagnóstico. Os exames por imuno-histoquímica demonstraram a presença de múltiplos hormônios, mas por falta de sintomas clínicos, as correlações ficaram prejudicadas na maioria dos casos, havendo correlação somente em caso de gastrinoma. Um paciente faleceu no pós-operatório; um sobreviveu sete anos e cinco estão vivos, com sobrevida variando entre três e cinco anos. CONCLUSÕES: Não houve uma manifestação sindrômica evidente, porém a sobrevida dos pacientes tem sido compatível com os dados de literatura.

BACKGROUND: The purpose of the present study is to analyze the difficulties concerning diagnostic, prognostic and clinical conduct of seven patients with pancreatic neuroendocrine tumors (APUDomas), evaluated over the past decade. METHODS: Patients varied in age from 15 to 66 years old, with a mean age of 38.4 years. All patients underwent some type of pancreatic resection as treatment of the neuroendocrine tumor. The histological sections were submitted to traditional and imunohistochemical examination. RESULTS: Three patients were diagnosed with unspecific neuroendocrine tumor, two with VIPoma and two with Gastrinoma. Syndromes were not clearly manifested, although every case had a differential diagnosis. Imunohistochemistry showed the presence of multiple hormones, but due to the lack of clinical symptoms, correlation was harmed in most cases, however one Gastrinoma showed typical clinical symptoms. One patient died in the post-operative period, one survived for 7 years and five are still alive, with a life expectancy varying from 3 to 5 years. CONCLUSIONS: We observed a lack of typical clinical syndromes for most cases, but life expectancy was compatible with the one described in the literature.

Literature has been showing a tendency of reducing the limits of Whipple's resection. The main technical advance was the pylorus preserving resection, technique proposed by Traverso and Longmire in 1978. The pancreticoduodenectomy for chronic pancreatitis, is probably the best opportunity to apply this type of procedure. In these specific patients, the author preserved the pylorus and the third portion of the duodenum. The gastrointestinal transit was reconstructed by the duodenumduodenal anastomosis and the bile duct and the pancreas were drained in a Roux-en-way loop . Follow-up showed no important complication, with no problems related to gastric emptying and without pain.