The COVID-19 pandemic has had a negative effect on surgical education in Latin America, decreasing residents’ surgical training and supervised clinical practice.
This study aimed to identify strategies that have been proposed or implemented to adapt surgical training and supervised clinical practice to COVID-19-related limitations in Latin America.
A literature review was performed between April and May 2021, divided into two searches. The first one sought to identify adaptation strategies in Latin America for surgical training and supervised clinical practice. The second one was carried out as a complement to identify methodologies proposed in the rest of the world.
In the first search, 16 of 715 articles were selected. In the second one, 41 of 1,637 articles were selected. Adaptive strategies proposed in Latin America focused on videoconferencing and simulation. In the rest of the world, remote critical analysis of recorded/live surgeries, intrasurgical tele-mentoring, and surgery recording with postoperative feedback were suggested.
Multiple adaptation strategies for surgical education during the COVID-19 pandemic have been proposed in Latin America and the rest of the world. There is an opportunity to implement new strategies in the long term for surgical training and supervised clinical practice, although more prospective studies are required to generate evidence-based recommendations.
Dysbiosis of the gut microbiota is frequently found in cases of obesity and related metabolic diseases, such as type 2 diabetes mellitus. The composition of the microbiota in diabetics is similar to that of obese people, thereby causing increased energy uptake efficiency in the large intestine of obese people, maintenance of a systemic inflammatory state, and increased insulin resistance. Bariatric surgery seems to entail an improvement in gut dysbiosis, leading to an increased diversity of the gut microbiota.
This study aimed to present a literature review on obesity-associated gut dysbiosis and its status post-bariatric surgery.
A systematic review of primary studies was conducted in PubMed, SciELO, BIREME, LILACS, Embase, ScienceDirect, and Scopus databases using DeCS (Health Science Descriptors) with the terms “obesity,” “intestinal dysbiosis,” “bariatric surgery,” and “microbiota.”
We analyzed 28 articles that had clinical studies or literature reviews as their main characteristics, of which 82% (n=23) corresponded to retrospective studies. The sample size of the studies ranged from 9 to 257 participants and/or fecal samples. The epidemiological profile showed a higher prevalence of obesity in females, ranging from 24.4 to 35.1%, with a mean age of around 25–40 years. There was a variation regarding the type of bariatric surgery, migrating between the Roux-en-Y bypass, adjustable gastric banding, and vertical gastrectomy. Of the 28 studies, 6 of them evaluated the gut microbiota of obese patients undergoing bariatric surgery and their relationship with type 2 diabetes mellitus/glucose metabolism/insulin resistance.
The intestinal microbiota is an important influencer in the regulation of the digestive tract, and obese individuals with comorbidities (diabetes mellitus, hypercholesterolemia, and metabolic syndrome) present important alterations, with an unbalance normal state, generating dysbiosis and the proliferation of bacterial species that favor the appearance of new diseases. Patients who undergo bariatric surgery present an improvement in the intestinal microbiota imbalance as well as reversibility of their comorbidities, increasing their life expectancy.
Plexiform neurofibromas represent a common neoplasia of type 1 neurofibromatosis in which neurofibromas arise from multiple nerves involving connective tissue and skin and rarely affect the colon and rectum. Co-occurrence of plexiform neurofibromas, neuroendocrine tumors with primary involvement of the rectum, and medullary thyroid carcinoma in patients with neurofibromatosis type 1 is a previously undescribed condition. The aim of this manuscript was to present a case of primary plexiform neurofibroma and neuroendocrine tumors of the upper rectum in a patient with neurofibromatosis type 1 whose genetic sequencing found a novel mutation in the neurofibromatosis type 1 gene and to review the literature.
A 49-year-old woman with a familial history of neurofibromatosis type 1 complained of abdominal cramps for 6 months. She had previously been submitted for a total thyroidectomy due to medullary thyroid carcinoma. She was submitted to a colonoscopy, which identified a submucosa lesion located in the upper rectum. The patient was referred for a laparoscopic rectosigmoidectomy, and the histopathological study of the surgical specimen identified two different tumors. An immunohistochemical panel was done for histopathological confirmation of the etiology of both lesions. The results of the panel showed intense immunoexpression of S100 protein in the largest and superficial lesion, as well as positivity for chromogranin and synaptophysin in the minor and deep lesion confirming the diagnosis of rectal plexiform neurofibromas concomitant with neuroendocrine tumors. The proliferative activity rate using Ki-67 antibodies showed that both tumors had a low rate of mitotic activity (<1%). Genetic sequence panel identified an undescribed mutation in the neurofibromatosis type 1 gene (deletion, exons 2–30). The patient’s postoperative evolution was uneventful, and she remains well, without recurrence, 3 years after surgery.
The co-occurrence of medullary thyroid carcinoma, plexiform neurofibromas, and neuroendocrine tumors of the rectum in patients with neurofibromatosis type 1 is an exceptional and undescribed possibility, whose diagnosis can be confirmed by the immunohistochemical staining and genetic panel.
Robotic-assisted surgery research has grown dramatically in the past two decades and the advantages over traditional videolaparoscopy have been extensively debated. For hernias, the robotic system can increase intraoperative strategies, especially in complex hernias or incisional hernias.
This study aimed to compare the direct cost differences between robotic and laparoscopic hernia repair and determine each source of expenditure that may be related to the increased costs in a robotic program from the perspective of a Brazilian public institution.
This study investigated the differences in direct costs from the data generated from a trial protocol (ReBEC: RBR-5s6mnrf). Patients with incisional hernia were randomly assigned to receive laparoscopic ventral incisional hernia repair (LVIHR) or robotic ventral incisional hernia repair (RVIHR). The direct medical costs of hernia treatment were described in the Brazilian currency (R$).
A total of 19 patients submitted to LVIHR were compared with 18 submitted to RVIHR. The amount spent on operation room time (RVIHR: 2,447.91±644.79; LVIHR: 1,989.67±763.00; p=0.030), inhaled medical gases in operating room (RVIHR: 270.57±211.51; LVIHR: 84.55±252.34; p=0.023), human resources in operating room (RVIHR: 3,164.43±894.97; LVIHR: 2,120.16±663.78; p<0.001), material resources (RVIHR: 3,204.32±351.55; LVIHR: 736.51±972.32; p<0.001), and medications (RVIHR: 823.40±175.47; LVIHR: 288.50±352.55; p<0.001) for RVIHR was higher than that for LVIHR, implying a higher total cost to RVIHR (RVIHR: 14,712.24±3,520.82; LVIHR: 10,295.95±3,453.59; p<0.001). No significant difference was noted in costs related to the hospital stay, human resources in intensive care unit and ward, diagnostic tests, and meshes.
Robotic system adds a significant overall cost to traditional laparoscopic hernia repair. The cost of the medical and robotic devices and longer operative times are the main factors driving the difference in costs.
Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, “recurrences” occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that “recurrence” actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure.
Surgical resection represents the main treatment for resectable nonmetastatic gastric gastrointestinal stromal tumors. Despite the feasibility and safety of laparoscopic resection, its standard use in gastric tumors larger than 5 cm is yet to be established.
This study aimed to compare the current evidence on laparoscopic resection with the classical open surgical approach in terms of perioperative, postoperative, and oncological outcomes.
The PubMed, Scopus, and Web of Science databases were consulted. Articles comparing the approach to gastric gastric gastrointestinal stromal tumors larger than 5 cm by open and laparoscopic surgery were eligible. A post hoc subgroup analysis based on the extent of the surgery was performed to evaluate the operative time, blood loss, and length of hospital stay.
A total of nine studies met the eligibility criteria. In the study, 246 patients undergoing laparoscopic surgery and 301 patients undergoing open surgery were included. The laparoscopic approach had statistically significant lower intraoperative blood loss (p=0.01) and time to oral intake (p<0.01), time to first flatus (p<0.01), and length of hospital stay (0.01), compared to the open surgery approach. No significant differences were found when operative time (0.25), postoperative complications (0.08), R0 resection (0.76), and recurrence rate (0.09) were evaluated. The comparative subgroup analysis between studies could not explain the substantial heterogeneity obtained in the respective outcomes.
The laparoscopic approach in gastric gastrointestinal stromal tumors larger than 5 cm compared to the open surgical approach is a technically safe and feasible surgical method with similar oncological results.
Solid pseudopapillary neoplasm of the pancreas is an uncommon pancreatic tumor, which is more frequent in young adult women. Familial adenomatous polyposis is a genetic condition associated with colorectal cancer that also increases the risk of developing other tumors as well.
The aim of this study was to discuss the association of familial adenomatous polyposis with solid pseudopapillary neoplasm of the pancreas, which is very rare.
We report two cases of patients with familial adenomatous polyposis who developed solid pseudopapillary neoplasm of the pancreas of the pancreas and were submitted to laparoscopic pancreatic resections with splenic preservation (one male and one female).
ß-catenin and Wnt signaling pathways have been found to play an important role in the tumorigenesis of solid pseudopapillary neoplasm of the pancreas, and their constitutive activation due to adenomatous polyposis coli gene inactivation in familial adenomatous polyposis may explain the relationship between familial adenomatous polyposis and solid pseudopapillary neoplasm of the pancreas.
Colonic resection must be prioritized, and a minimally invasive approach is preferred to minimize the risk of developing desmoid tumor. Pancreatic resection usually does not require extensive lymphadenectomy for solid pseudopapillary neoplasm of the pancreas, and splenic preservation is feasible.
Dyspepsia is a set of symptoms of the upper abdomen and has a prevalence of 10–45% of the population with different etiological possibilities, including celiac disease.
The aim of this study was to evaluate the prevalence of celiac disease in patients with a clinical diagnosis of dyspeptic syndrome.
This is an observational research, based on a review of medical records of patients treated for uninvestigated dyspepsia. Patients over 18 years of age, with uninvestigated dyspepsia, and who had upper endoscopy, total immunoglobulin A (IgA), and antitissue transglutaminase IgA were included. Those with diarrhea, constipation, malabsorption, refractory lactose intolerance, or who presented extraintestinal signs or symptoms suggestive of celiac disease were excluded.
The initial sample was 1,802 records and the final 200 patients. Considering the total sample, the average age was 45.13 years and the female sex was predominant. Symptoms associated with gluten were reported in 6% of the patients. The antitissue transglutaminase IgA was positive in 1.5% of the patients. Considering the sample of 100 patients, the diagnosis of celiac disease had a prevalence of 3%.
The prevalence of celiac disease in patients with a clinical diagnosis of dyspeptic syndrome was 3%.
The surgical approach for esophagogastric junction cancers (EJC), Siewert II, has been controversial regarding margin control, reconstruction, and lymphadenectomy extension. Therefore, predicting the need for total/subtotal esophagectomy and proximal gastrectomy (TEPG) or total gastrectomy with distal esophagectomy (TGDE) can be challenging, with each direction usually excluding the other. Historically, complication rates for TEPG are higher, affecting further systemic treatment and long-term outcomes.
The aim of this study was to describe a surgical strategy for approaching tumors such as Siewert II EGJ, with the intraoperative decision to perform total gastrectomy with lymphadenectomy D2 or esophagectomy with lymphadenectomy based on intraoperative frozen sections.
All patients underwent laparotomy, beginning with greater curvature detachment while preserving the right gastroepiploic, right and left gastric arteries; dissection of the esophageal hiatus for node harvesting; and transection of the distal esophagus and its frozen section. TGDE was preferred if the proximal margin of the distal esophagus was negative; TEPG and gastric tube reconstruction were performed through transhiatal access if the margin was positive.
Among 38 Siewert II patients, 26 (69%) underwent TGDE and 12 (31%) underwent TEPG, regardless of the trend toward higher complication rates, positive margins, and shorter overall survival in the TEPG group, no statistically significant differences were detected.
Although no significant differences in morbidity between the two procedures were noted, type II errors could be a possible cause. This study suggests that unnecessary esophagectomies can be avoided without jeopardizing surgical or oncologic outcomes by opting for a less morbid procedure.
Orthotopic liver transplantation (OLT) is a highly complex procedure, which can be difficult to control intraoperatively in patients with coagulopathies.
The aim of this study was to evaluate the prophylactic administration of epsilon aminocaproic acid (EACA) to reduce the need for transfusion of blood products and its relevance for thrombosis.
Patients were randomized into two groups: one group received EACA (20 mg/kg/h) before surgical incision until the end of OLT and a control group received a similar volume of 0.9% saline solution. Blood was collected to analyze fibrinolysis and coagulation disorders using rotational thromboelastometry (ROTEM®).
A total of 24 patients received EACA and 26 patients received saline solution. In the analysis of the fibrinolytic and hemostatic coagulation profile by ROTEM®, fibrinolysis was significantly less frequent in the group of patients treated with EACA (p<0.001) in the anhepatic phase. There were no significant differences in the other extrinsic pathway thromboelastometry and fibrinogen-specific thromboelastometry analyses. In addition, there were no significant differences between both groups regarding the average and percentage transfusion of blood products, postoperative complications, patients who were discharged from the hospital, and those who died within 3 months after liver transplantation.
Although the administration of EACA did not reduce the transfusion of blood products, this drug effectively treated fibrinolysis and was not associated with any complications with increased risk of vein and hepatic artery thrombosis or mortality within 3 months after liver transplantation.
A total of 105 patients were assessed for eligibility, and 55 were excluded. The remaining 50 patients were randomized, of which 24 patients were allocated to the intervention group and the other 26 to the saline placebo group. In the analysis of the fibrinolytic and hemostatic coagulation profile by rotational thromboelastometry, fibrinolysis was significantly less frequent in patients treated with epsilon aminocaproic acid (p<0.001) compared to those in the placebo group during the anhepatic phase. In the other analyses using thromboelastometry assays such as extrinsic pathway thromboelastometry (EXTEM) (clotting time [CT], clot formation time, alpha angle, amplitude of clot firmness 10 min after CT [A10], and maximum clot firmness [MCF]) and fibrinogen-specific thromboelastometry (FIBTEM) (A10 and MCF), there was no significant difference nor postoperative complications in both groups.
Some studies have shown that epsilon aminocaproic acid (EACA) inhibits the binding of plasminogen to lysine residues on the surface of fibrin and prevents conversion of plasminogen to plasmin and the degradation of glycoprotein Ib receptors, thus preserving platelet function. Although EACA did not reduce blood product transfusion, the drug effectively treated all cases and was not associated with any complications of increased risk of hepatic artery and vein thrombosis or mortality within 3 months after orthotopic liver transplantation (OLT). These results support the safety of EACA as the antifibrinolytic drug of choice in OLT. However, future studies involving larger randomized clinical trials and higher doses are needed to further investigate the results.
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