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The unresectable pancreatic head tumors develop obstructive jaundice and cholestasis during follow-up. Cholestasis is associated with complications and treatment options are endoscopic stenting (ES) and biliary bypass surgery (BBS).
The aim of the current study was to compare the safety and efficacy of biliary bypass surgery (BBS) and endoscopic stenting (ES) for cholestasis in advanced pancreas cancer.
This is a retrospective cohort of patients with cholestasis and unresectable or metastatic pancreas cancer, treated with BBS or ES. Short and long-term outcomes were evaluated. We considered the need for hospital readmission due to biliary complications as treatment failure.
A total of 93 patients (BBS=43; ES=50) were included in the study. BBS was associated with a higher demand for postoperative intensive care (37 vs.10%; p=0.002, p<0.050), longer intensive care unit stay (1.44 standard deviation±2.47 vs. 0.66±2.24 days; p=0.004, p<0.050), and longer length of hospital stay (7.95±2.99 vs. 4.29±5.50 days; p<0.001, p<0.050). BBS had a higher risk for procedure-related complications (23 vs. 8%; p=0.049, p<0.050). There was no difference in overall survival between BBS and ES (p=0.089, p>0.050). ES was independently associated with a higher risk for treatment failure than BBS on multivariate analysis (hazard ratio 3.97; p=0.009, p<0.050).
BBS is associated with longer efficacy than ES for treating cholestasis in advanced pancreatic cancer. However, the BBS is associated with prolonged intensive care unit and hospital stays and higher demand for intensive care.
Mechanic sutures represent an enormous benefit for digestive surgery in decreasing postoperative complications. Currently, the advantages of motorized stapler are under evaluation.
To compare the efficacy of mechanic versus motorized stapler in gastric surgery, analyzing rate of leaks, bleeding, time of stapling, and postoperative complications.
Ninety-eight patients were submitted to gastric surgery, divided into three groups: laparoscopic sleeve gastrectomy (LSG) (n=47), Roux-en-Y gastric bypass (LRYGB) (n=30), and laparoscopic distal gastrectomy (LDG) (n=21). Motorized staplers were employed in 61 patients. The number of firings, number of clips, time of total firings, total time to complete the surgery, and postoperative outcome were recorded in a specific protocol.
Patients submitted to LSG, LRYGB, and LDG recorded a shorter time to complete the procedure and a smaller number of firings were observed using motorized stapler (p<0.0001). No differences were identified regarding the number of clips used in patients submitted to LSG. In the group that used mechanic stapler to complete gastrojejunostomy, jejuno-jejuno-anastomosis, and jejunal transection, it was observed more prolonged time of firing and total time for finishing the procedure (p=0.0001). No intraoperative complications were found comparing the two devices used. Very similar findings were noted in the group of patients undergoing LDG.
The motorized stapler offers safety and efficacy as demonstrated in prior reports and is relevant since less total time of surgical procedure without intraoperative or postoperative complications were confirmed.
The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first.
Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT.
This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis.
Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct.
There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.
Colorectal cancer is the third most common type of cancer in Brazil, despite the availability of screening methods that reduce its risk. Colonoscopy is the only screening method that also allows therapeutic procedures. The proper screening through colonoscopy is linked to the quality of the exam, which can be evaluated according to quality criteria recommended by various institutions. Among the factors, the most used is the Adenoma Detection Rate, which should be at least 25% for general population.
To evaluate the quality of the screening colonoscopies performed in a quarternary private Brazilian hospital.
This is a retrospective study evaluating the quality indicators of colonoscopies performed at a private center since its inauguration. Only asymptomatic patients aged over 45 years who underwent screening colonoscopy were included. The primary outcome was the Adenoma Detection Rate, and secondary outcomes included polyps detection rate and safety profile. Subanalyses evaluated the correlation of endoscopic findings with gender and age and the evolution of detection rates over the years.
A total of 2,144 patients were include with a mean age of 60.54 years-old. Polyps were diagnosed in 68.6% of the procedures. Adenoma detection rate was 46.8%, with an increasing rate over the years, mainly in males. A low rate of adverse events was reported in 0.23% of the cases, with no need for surgical intervention and no deaths.
This study shows that high quality screening colonoscopy is possible when performed by experienced endoscopists and trained nurses, under an adequate infrastructure.
Maintaining normal intra-abdominal pressure (IAP) levels must be one major outcome of any ventral hernia repair, avoiding hypertension or abdominal compartment syndrome.
To evaluate IAP during ventral hernia repair using Lázaro da Silva’s procedure.
IAP measurements using intravesical pressure were performed during four crucial intraoperative moments. Twenty-eight patients submitted to incisional herniorrhaphy were analyzed.
The IAP increased by 0.5 mmHg during the procedure, regardless of the type of prior laparotomy, sex, age, obesity, or hernia width.
Despite the IAP increase observed, Lázaro da Silva’s procedure did not result in intra-abdominal hypertension or abdominal compartment syndrome.
Despite the preference for multimodal treatment for gastric cancer, abandonment of chemotherapy treatment as well as the need for upfront surgery in obstructed patients brings negative impacts on the treatment. The difficulty of accessing treatment in specialized centers in the Brazilian Unified National Health System (SUS) scenario is an aggravating factor.
To identify advantages, prognostic factors, complications, and neoadjuvant and adjuvant therapies survival in gastric cancer treatment in SUS setting.
The retrospective study included 81 patients with gastric adenocarcinoma who underwent treatment according to INT0116 trial (adjuvant chemoradiotherapy), CLASSIC trial (adjuvant chemotherapy), FLOT4-AIO trial (perioperative chemotherapy), and surgery with curative intention (R0 resection and D2 lymphadenectomy) in a single cancer center between 2015 and 2020. Individuals with other histological types, gastric stump, esophageal cancer, other treatment protocols, and stage Ia or IV were excluded.
Patients were grouped into FLOT4-AIO (26 patients), CLASSIC (25 patients), and INT0116 (30 patients). The average age was 61 years old. More than 60% of patients had pathological stage III. The treatment completion rate was 56%. The pathological complete response rate of the FLOT4-AIO group was 7.7%. Among the prognostic factors that impacted overall survival and disease-free survival were alcoholism, early postoperative complications, and anatomopathological status pN2 and pN3. The 3-year overall survival rate was 64.9%, with the CLASSIC subgroup having the best survival (79.8%).
The treatment strategy for gastric cancer varies according to the need for initial surgery. The CLASSIC subgroup had better overall survival and disease-free survival. The INT0116 regimen also protected against mortality, but not with statistical significance. Although FLOT4-AIO is the preferred treatment, the difficulty in carrying out neoadjuvant treatment in SUS scenario had a negative impact on the results due to the criticality of food intake and worse treatment tolerance.
Deep penetrating endometriosis (DE) can affect abdominal and pelvic organs like the bowel and bladder, requiring treatment to alleviate symptoms.
To study and investigate clinical and surgical outcomes in patients diagnosed with DE involving the intestines, aiming to analyze the effectiveness of surgical treatments.
All cases treated from January 2021 to July 2023 were included, focusing on patients aged 18 years or older with the disease affecting the intestines. Patients without intestinal involvement and those with less than six months of post-surgery follow-up were excluded. Intestinal involvement was defined as direct invasion of the intestinal wall or requiring adhesion lysis for complete resection. Primary outcomes were adhesion lysis, rectal shaving, disc excision (no-colectomy group), and segmental resection (colectomy group) along with surgical complications like anastomotic leak and fistulas, monitored for up to 30 days.
Out of 169 patients with DE surgically treated, 76 met the inclusion criteria. No colectomy treatment was selected for 50 (65.7%) patients, while 26 (34.2%) underwent rectosigmoidectomy (RTS). Diarrhea during menstruation was the most prevalent symptom in the RTS group (19.2 vs. 6%, p<0.001). Surgical outcomes indicated longer operative times and hospital stays for the segmental resection group, respectively 186.5 vs. 104 min (p<0.001) and 4 vs. 2 days, (p<0.001). Severe complications (Clavien-Dindo ≥3) had an overall prevalence of 6 (7.9%) cases, without any difference between the groups. There was no mortality reported. Larger lesions and specific symptoms like dyschezia and rectal bleeding were associated with a higher likelihood of RTS. Bayesian regression highlighted diarrhea close to menstruation as a strong predictor of segmental resection.
In patients with DE involving the intestines, symptoms such as dyschezia, rectal bleeding, and menstrual period-related diarrhea predict RTS. However, severe complication rates did not differ significantly between the segmental resection group and no-colectomy group.
Predicting short- and long-term outcomes of oncological therapies is crucial for developing effective treatment strategies. Malnutrition and the host immune status significantly affect outcomes in major surgeries.
To assess the value of preoperative prognostic nutritional index (PNI) in predicting outcomes in gastric cancer patients.
A retrospective cohort analysis was conducted on patients undergoing curative-intent surgery for gastric adenocarcinoma between 2009 and 2020. PNI was calculated as follows: PNI=(10 x albumin [g/dL])+(0.005 x lymphocytes [nº/mm3]). The optimal cutoff value was determined by the receiver operating characteristic curve (PNI cutoff=52), and patients were grouped into low and high PNI.
Of the 529 patients included, 315 (59.5%) were classified as a low-PNI group (PNI<52) and 214 (40.5%) as a high-PNI group (PNI≥52). Older age (p=0.050), male sex (p=0.003), American Society of Anesthesiologists score (ASA) III/IV (p=0.001), lower hemoglobin level (p<0.001), lower body mass index (p=0.001), higher neutrophil-lymphocyte ratio (p<0.001), D1 lymphadenectomy, advanced pT stage, pN+ and more advanced pTNM stage were related to low-PNI patient. Furthermore, 30-day (1.4 vs. 4.8%; p=0.036) and 90-day (3.3 vs. 10.5%; p=0.002) mortality rates were higher in low-PNI compared to high-PNI group. Disease-free and overall survival were worse in low-PNI patients compared to high-PNI (p<0.001 for both). ASA III/IV score, low-PNI, pT3/T4, and pN+ were independent risk factors for worse survival.
Preoperative PNI can predict short- and long-term outcomes of patients with gastric cancer after curative gastrectomy. Low PNI is an independent factor related to worse disease-free and overall survival.
Bariatric surgery can cause oral health problems in individuals, such as an increase in dental caries, periodontal diseases and dental erosion, which can be avoided if oral health promotion actions are implemented.
To assess the impact of an oral health promotion program implemented among gastroplasty patients.
This randomized clinical trial involved 208 patients undergoing gastroplasty; they were divided into two groups: Intervention Group, with participation in the Oral Health Promotion Program for Bariatric Patients, or Control Group. Assessments were carried out preoperatively, and six and 12 months postoperatively. The oral conditions assessed were: dental caries, periodontal diseases, tooth wear, dental plaque, and salivary flow. Sociodemographic information was obtained through application of structured questionnaires. For data analysis, the Chi-Square, Fisher’s Exact, and Mann-Whitney tests were performed — α=5%.
Patients in the Intervention Group, when compared to those in the Control Group, presented: fewer changes in enamel (6M: p<0.0001; 12M: p=0.001), in dentin (6M: p<0.0001; 12M: p<0.0001), moderate tooth wear (6M=0.002; 12M=0.005), gingival bleeding (6M: p<0.0001), dental calculus (6M=0.002; 12M: p=0.03), periodontal pocket 4-5 mm (6M=0.001; 12M: p=<0.0001); greater reduction in the bacterial plaque index (6M: p<0.0001; 12M: p<0.0001), and increased salivary flow (6M: p=0.019).
The oral health promotion program had a positive impact on the prevention and control of the main problems to the oral health of the gastroplasty patients.
Results on quality of life after inguinal hernia surgery, such as esthetics, postoperative pain, period of absence from activities, and recurrence are a relevant topic since inguinal hernia affects 27% of men and 3% of women at some point in their lives, and should guide health policies to allocate resources more efficiently.
To evaluate the quality of life in the late postoperative period of inguinal herniorrhaphy regarding recurrence, pain, esthetics, and restriction in activities, comparing the minimally invasive techniques — the transabdominal preperitoneal (TAPP) and the conventional Lichtenstein.
A cross-sectional observational clinical study was conducted with the EuraHS-QoL questionnaire validated and translated into Portuguese, applied to patients after an average of 65 months postoperatively. Forty-five patients were assessed, 28 undergoing Lichtenstein and 17 undergoing TAPP. All were males aged between 18 and 87 years with a primary unilateral inguinal hernia. Recurrent or bilateral hernias, other concomitant abdominal wall hernias, patients who chose not to participate or who were not found, and female patients were excluded from the study.
Regarding the domains pain, restriction, and esthetics, there was no difference between the two groups when examining quality of life. Neither group presented recurrence in the studied period.
Both TAPP and Lichtenstein techniques presented similar results concerning quality of life when compared in the long-term.
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