ABSTRACT
BACKGROUND:
Liver transplantation (LT) is the only treatment that can provide long-term survival for patients with acute-on-chronic liver failure (ACLF). Although several studies identify prognostic factors for patients in ACLF who do not undergo LT, there is scarce literature about prognostic factors after LT in this population.
AIM:
Evaluate outcomes of ACLF patients undergoing LT, studying prognostic factors related to 1-year and 90 days post-LT.
METHODS:
Patients with ACLF undergoing LT between January 2005 and April 2021 were included. Variables such as chronic liver failure consortium (CLIF-C) ACLF values and ACLF grades were compared with the outcomes.
RESULTS:
The ACLF survival of patients (n=25) post-LT at 90 days, 1, 3, 5 and 7 years, was 80, 76, 59.5, 54.1 and 54.1% versus 86.3, 79.4, 72.6, 66.5 and 61.2% for patients undergoing LT for other indications (n=344), (p=0.525). There was no statistical difference for mortality at 01 year and 90 days among patients with the three ACLF grades (ACLF-1 vs. ACLF-2 vs. ACLF-3) undergoing LT, as well as when compared to non-ACLF patients. CLIF-C ACLF score was not related to death outcomes. None of the other studied variables proved to be independent predictors of mortality at 90 days, 1 year, or overall.
CONCLUSIONS:
LT conferred long-term survival to most transplant patients. None of the studied variables proved to be a prognostic factor associated with post-LT survival outcomes for patients with ACLF. Additional studies are recommended to clarify the prognostic factors of post-LT survival in patients with ACLF.
ABSTRACT
BACKGROUND:
Minimally invasive distal pancreatectomy (MIDP) is associated with less blood loss and faster functional recovery. However, the benefits of robotic assisted distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) are unknown.
AIMS:
To compare RDP versus LDP for surgical treatment of benign lesions, pre-malignant and borderline malignant pancreatic neoplasias.
METHODS:
This is a retrospective study comparing LDP with RDP. Main outcomes were overall morbidity and overall costs. Secondary outcomes were pancreatic fistula (PF), infectious complications, readmission, operative time (OT) and length of hospital stay (LOS).
RESULTS:
Thirty patients submitted to LDP and 29 submitted to RDP were included in the study. There was no difference regarding preoperative characteristics. There was no difference regarding overall complications (RDP – 72,4% versus LDP – 80%, p=0,49). Costs were superior for patients submitted to RDP (RDP=US$ 6,688 versus LDP=US$ 6,149, p=0,02), mostly due to higher costs of surgical materials (RDP=US$ 2,364 versus LDP=1,421, p=0,00005). Twenty-one patients submitted to RDP and 24 to LDP developed pancreatic fistula (PF), but only 4 RDP and 7 LDP experienced infectious complications associated with PF. OT (RDP=224 min. versus LDP=213 min., p=0.36) was similar, as well as conversion to open procedure (1 RDP and 2 LDP).
CONCLUSIONS:
The postoperative morbidity of robotic distal pancreatectomy is comparable to laparoscopic distal pancreatectomy. However, the costs of robotic distal pancreatectomy are slightly higher.
ABSTRACT
BACKGROUND:
Bariatric surgery is the best treatment option for patients with obesity. As a result of the advancement of technology, the robotic gastric bypass presents promising results, despite its still high costs.
AIMS:
The aim of this study was to compare patients submitted to a robotic versus a laparoscopic gastric bypass at a single center by a single surgeon.
METHODS:
This retrospective study collected data from the medical records of 221 patients (121 laparoscopic procedures versus 100 with daVinci platform). The variables analyzed were sex, age, body mass index, comorbidities, surgical time, length of stay, and complications.
RESULTS:
The mean surgical time for patients in the robotic group was shorter (102.41±39.44 min versus 113.86±39.03 min, p=0.018). The length of hospital stay in robotic patients was shorter (34.12±20.59 h versus 34.93±11.74 h, p=0.007). There were no serious complications.
CONCLUSIONS:
The group submitted to the robotic method had a shorter surgical time and a shorter hospital stay. No difference was found regarding strictures, bleeding, or leakage.
ABSTRACT
BACKGROUND:
Adhesive small bowel obstruction is one of the most common causes of surgical emergencies, representing about 15% of hospital admissions. Defining the need and timing of surgical intervention still remains a challenge.
AIMS:
To report the experience of using meglumine-based water-soluble contrast in a tertiary hospital in southern Brazil, comparing with the world literature.
METHODS:
Patients suspected of having adhesive small bowel obstruction, according to their clinical conditions, underwent an established protocol, consisting of the administration of water-soluble contrast, followed by plain abdominal radiograph within 12 hours and by a new clinical evaluation. The protocol was initiated after starting conservative management, including fasting and placement of a nasogastric tube, as well as intravenous fluid reposition.
RESULTS:
A total of 126 patients were submitted to the protocol. The water-soluble contrast test sensitivity and specificity after the first radiograph were 94.6 and 91.0%, respectively; after the second radiograph, these values were 92.3 and 100%. The general test values for sensitivity and specificity were 91.9 and 100%, respectively.
CONCLUSIONS:
The measure parameters evaluated in this study were similar to those found in the literature, contributing to endorse the importance of this test in the evaluation of patients with adhesive small bowel obstruction. The particular relevance of this study was the similar results that were found using a different type of meglumine-based contrast, which is available in Brazil.
HEADINGS
Intestinal Obstruction; Contrast Media; Laparotomy
BACKGROUND: Staple line leaks carry significant morbidity and mortality. Reinforcement is controversial. Several staple techniques have been described for this purpose. Oversuture and butressing material are more common. AIM: To compare these two ways of reinforcement and staple line without any reinforcement regarding the bursting pressure. METHOD: Ten segments of small bowel were created in a pig under general anesthesia. The bowel was inflatted until burst point and the pressure was measured. RESULTS: The staple line bursting pressure was 94 mmHg +/- 18,52mmHg in the stapler technique; 87,5 mmHg +/- 18,59mmHg in the oversuture and 83,33 mmHg +/- 23,04mmHg with Surgisis®. There was no statistic difference among the techniques. CONCLUSIONS: Oversuture or Surgisis® use did not increase the staple line resistance in pig.
BACKGROUND: Several surgical techniques have been developed over the past years, and total extraperitoneal and transabdominal preperitoneal inguinal hernia repair are the endoscopic techniques that are most commonly used. AIM: To describe and discuss Dulucq's technique and the modifications of using 3-D mesh in total extraperitoneal inguinal hernia repair. METHODS: Patients who underwent an elective inguinal hernia repair were enrolled prospectively in this study. Operative and postoperative course were studied. RESULTS: A total of 261 hernia repairs were included in the study. The hernias were repaired by total extraperitoneal technique; two hernias (0.75%) were converted to open anterior Liechtenstein technique. Mean operative time was 43.38 min in unilateral hernia and 53.36 min in bilateral hernia. Most of the patients (95%) were discharged at the same day of the surgery. The overall postoperative morbidity rate was 5.7%. The incidence of recurrence rate was 0.0% in median follow-up period of 26 months. CONCLUSION: Total extraperitoneal hernioplasty is a very effective and safe procedure in the hands of experienced surgeons with specific training. It is an interesting option in bilateral and recurrent hernia as it obtains satisfactory results in terms of postoperative pain and morbidity.
BACKGROUND: Neoadjuvant treatment with radiotherapy and chemotherapy is the preferred regimen for locally advanced rectal cancer, aiming to increase resectability and decrease local recurrence. AIM: To evaluate the benefits of delayed surgery after neoadjuvant chemoradiation in advanced rectal cancer regarding aspects of tumor response, survival and its deleterious effects. METHODS: Were treated 106 patients consecutively with locally advanced rectal adenocarcinoma. Neoadjuvant chemoradiation with a dose of 50.4 Gy (28 fractions), 5-fluoracil and leucovorin was given. Surgery was scheduled within five to six weeks. Patients who returned later than six weeks for the scheduled surgery were grouped into the delayed group and variables such as the downstaging rate, complete response, surgical time, blood transfusion, local recurrence, distant metastasis and survival were correlated with the remaining patients in order to determine the benefits of the delayed surgery. RESULTS: Complete tumor response was found in 15 patients (T0=15/106 - 14.2%). Partial response was achieved in 38 patients (34.9%), while one patient had pT0N2 staging. The mean follow-up was 35.6 weeks for the six weeks group, and 32.2 weeks for the delayed group. There were no significant differences between the two groups in terms of downstaging, complete tumor response, surgical time, blood transfusion and early post-operative complications. Although delayed surgery didn't have a significant difference regarding the local recurrence (p=0.1468), it showed a strong tendency in the delayed group of having a lower risk of distant metastasis (p=0.0520). CONCLUSION: Delayed surgery after chemoradiation offered no clear benefits in terms of complete tumor response or downstaging. Predictive molecular factors should be investigated in the future for the proper selection of patients who will benefit from chemoradiation.
BACKGROUND: Neuroendocrine tumors (NETs) are rare, comprising nearly 0.49% of all malignancies. The majority occurs in the gastrointestinal tract. AIM: To analyze the demographic factors, clinicopathologic features, treatment employed, prognostic factors and the oncologic results related to colorectal NETs. METHODS: Between the period from 1996 to 2010 174 patients were treated. From these, 34 were localized in the colon and rectum. Demographic factors, stage, therapeutics and its results were analyzed. All patients were followed for more than three years with image exams, urinary 5-hydroxyindolacetic acid (5-HIIA), serum chromogranin A and prostatic acid phosphatase. RESULTS: The median age was 54,4 years (22-76), the majority was female (64,7%). Out of the 12 patients with colon NETs, one (8.3%) patient was classified as Stage IA; one (8.3%) as Stage IB; three (25%) as Stage IIIB and seven (58.4%) as Stage IV. Out of the 22 patients with rectum NETs, six (27.3%) were classified as Stage IA; four (18.2%) as IB; three (13.6 %) as IIIA; one (4.5%) as IIIB and eight (36.4%) as IV. Of rectal NETs, nine (41%) were treated with endoscopic resection, six (27.2%) underwent conventional surgical treatment and six (27.2%) were treated with chemotherapy. Eleven patients with colon NETs (91.6%) were surgically treated, seven of them with palliative surgery, one (8.4%) was treated with endoscopic resection and no patient was submitted to chemotherapy. After an average follow-up of 55 months, 19 (55%) patients were alive. Analyzing the overall survival was obtained an average overall survival of 29 months in Stage IA, 62 months in IB, 12 months in IIIA, 31 months in IIIB and 39 months in IV. CONCLUSION: The treatment of colon and rectal NETs is complex, because it depends of the individuality of each patient. With adequate management, the prognosis can be favorable with long survival, but it is related to the tumor differentiation degree, efficacy of the chosen treatment and to the patient adhesion to the follow-up after treatment.
BACKGROUND: Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable. AIM: To present the Brazilian experience with ALPPS approach. METHOD: Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years). RESULTS: The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients). CONCLUSION: The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.
BACKGROUND: The success of a transplant depends mainly on the viability of the graft, which is currently the main point of difficulty focuses on the triad preservation-rejection-infection. There are several specific components of preservation solutions that could prevent certain tissue damage. From these components, the osmotic factor has been highlighted as a factor in preventing edema and subsequent cell death, suggesting a possible advantage in the use of hypertonic solutions for organ preservation. AIM: To compare different hypertonic solutions as alternative to liver preservation. METHOD: A total of 105 Wistar rats were divided in Standard Group (GP, n=5 rats), to verify the normal range of the study, and five experimental groups of 20 rats each, according to the preservation solution used: Group Eurocollins (GE), Group Saline 0.9% (GF), Group Glucose 50% (GG), Group Mannitol 20% (GM), Group Salty - NaCl 7.5% (GS). All animals in experimental group were also divided into four subgroups according to the time of collection in: 0 h, 2 h, 6 h and 12 h. Was assessed cell viability by the reaction with Methyl Blue Thiazolyl (MTT) and the dosages of lactate and alanine aminotransferase (ALT). RESULTS: Regarding the lactate level, was observed a relative improvement of hypertonic solutions compared to eurocollins, and in 12 h, the GE and GS showed no statistically significant difference (p> 0.05). When assessed cell viability, absorbance at MTT also demonstrated favorable results to the GS, since no statistically significant difference in relation to GE. CONCLUSION: The 7.5% NaCl solution showed promising results for organ preservation, presenting parameters and capability comparable to eurocollins preservation solution.
