Laparoscopic cholecystectomy is considered safe; however, it is not free from complications, such as bile duct injuries, bleeding, and infection of the surgical site.
The aim of this study was to determine the effectiveness of two prediction tools, the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) calculator and the surgical Apgar, in predicting post-cholecystectomy complications.
A cross-sectional, analytical, and comparative study was conducted on patients over 18 years old diagnosed with acute cholecystitis who underwent open or laparoscopic cholecystectomy at the Regional Teaching Hospital of Trujillo between 2015 and 2019. A chi-square test was used for bivariate analysis, and the receiver operating characteristic (ROC) curve analysis was employed to determine the discriminative capacity of the ACS-NSQIP and surgical Apgar calculators in predicting severe complications.
A total of 227 patients were included in the study. The analysis revealed that the mean age of patients who experienced severe complications was 75.32±4.58 years. Additionally, 52.6% of these patients were male. Regarding the prediction analysis based on the ROC curve, the ACS-NSQIP calculator showed an area under the curve of 0.895 (95%CI 0.819–0.971; p=0.01), whereas the surgical Apgar calculator showed an area under the curve of 0.611 (95%CI 0.488–0.735; p=0.11).
The obtained results indicate that the ACS-NSQIP calculator is effective in predicting severe complications in patients undergoing cholecystectomy due to acute cholecystitis. These findings may have important implications for clinical practice and medical decision-making, focusing on the appropriate use of prediction tools to improve outcomes in this type of surgical procedure.
Hepatocellular carcinoma (HCC) encompasses rare variants like chromophobe hepatocellular carcinoma (CHCC) characterized by distinct histological features and molecular profiles.
A 56-year-old male with chronic hepatitis C, presenting pain in the right hypochondrium. Imaging revealed a solitary liver lesion, subsequently resected and histologically diagnosed as HCC. Macroscopic examination found a 4×4 cm encapsulated liver nodule with necrotic areas, surrounded by numerous smaller satellite nodules in Segment 6. The liver was in micronodular cirrhosis. Histologically, the tumor had focal trabecular or pseudoglandular patterns within a vascularized stroma. The cells were large, with clear to eosinophilic cytoplasm and hyperchromatic and pleomorphic nuclei with focal anaplastic features. No vascular invasion was noted in adjacent cirrhotic liver tissue.
The final diagnosis was CHCC. Due to its rarity and overlapping characteristics with other hepatic tumors, CHCC poses diagnostic challenges. Accurate diagnosis necessitates thorough histopathological assessment and molecular testing. The identification of the alternative lengthening of telomeres phenotype may distinguish CHCC from conventional HCC and hold potential implications for targeted therapeutic approaches.
Recognition of HCC variants is critical for effective management and underscores the need for continued research into its clinical behavior and therapeutic responses.
Blood loss during liver transplantation (LT) remains a major concern associated with increased morbidity and reduced patient and graft survival. The high complexity of the procedure associated with the multifaceted origin of the bleeding urges early identification of high-risk patients and proper monitoring of hemostasis disorders in order to improve results. The accuracy of international normalized ratio (INR) and activated partial thromboplastin time (aPTT) to evaluate coagulation status in cirrhotic patients has been doubted.
The aim of this study was to investigate the applicability of these coagulation tests to indicate fresh frozen plasma transfusion in LT.
This retrospective cohort study analyzed 297 cirrhotic patients submitted to LT. INR and aPTT were measured preoperatively and in each surgical phase. Hemostatic blood components were transfused only for coagulopathy indication. Patients were divided according to intraoperative plasma transfusion into transfused and non-transfused groups. The accuracy of INR and aPTT to predict plasma transfusions was investigated. The alert values of INR and aPTT unassociated with coagulopathy in each phase of surgery were identified.
Multivariate analysis showed that preoperative hematocrit (odds ratio [OR]=0.90, p<0.001), preoperative fibrinogen (OR=0.99, p<0.001), and absence of hepatocellular carcinoma (OR=3.57, p=0.004) were significant predictors of plasma transfusions.
INR and aPTT demonstrated poor accuracy in predicting plasma transfusions, irrespective of the cutoff adopted, highlighting the need for a more comprehensive approach to guide hemostatic therapy in LT to improve the outcome.
The medical residency model, established over a century ago, remains the gold standard for medical education. Given its increasing significance in imparting expertise in medical specialties, understanding the profile of residents and changes over time is crucial.
This study aimed to assess graduates of digestive surgery and coloproctology residency programs at Hospital das Clínicas of the Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) regarding their professional, academic, and research activities. It also aimed to analyze changes in resident profiles over the years, the impact of postgraduation on professional activities, and differences between graduates working in São Paulo capital and elsewhere.
A digital survey with 42 questions was sent to graduates who commenced training between 1979 and 2021. Results were analyzed in subgroups based on two eras (Era 1: 1979–2000; Era 2: 2001–2021), the impact of postgraduation, and respondents’ work locations.
The survey was responded by 213 graduates (87.6%). The training significantly impacted all respondents’ professional lives, with 92.5% willing to choose the same specialty again. Graduates from Era 2 showed a higher proportion of females, residents of cities other than São Paulo, and graduates from institutions outside FMUSP. Postgraduate responders were more involved in academic and research activities, publishing more papers, holding societal memberships, and performing more robot-assisted procedures. Those outside São Paulo capital were more involved in endoscopic procedures and associated with medical insurance.
The majority of graduates considered medical residency fundamental for career development. Social and economic changes influenced residents’ profiles and post-program activities.
Cholangiocarcinoma (CCA) is a rare neoplasm, with high mortality, originating in the bile ducts. Its incidence is higher in Eastern countries due to the endemic prevalence of liver parasites. Factors such as metabolic syndrome, smoking, and pro-inflammatory conditions are also linked to the disease. Clinical features include asthenia, abdominal pain, cholestasis, and increased serum levels of CEA and CA19-9.
The aim of this study was to evaluate CCA prevalence, survival, and potential prognostic and therapeutic implications in a patient cohort and assess correlations with clinical laboratory data and possible associated risk factors.
This is a retrospective study of the clinical and histological data of patients diagnosed with CCA at Santa Casa de Misericórdia in Porto Alegre, Brazil, between 2016 and 2021.
There was a 56% prevalence of CCA in women, with intrahepatic localization in 55.4% of cases and unifocality in 85.6% of patients. The mean age of the patients was 63 years (26–89 years), with a mean tumor size of 5.5 cm. The median survival time was 7 months (0 to >50). CA19-9 was altered in 81% of patients, whereas GOT/GPT was altered in 62.5% and gamma-glutamyl transferase/alkaline phosphatase/bilirubin in 69.1% of patients. Mortality was higher among patients with extrahepatic CCA.
Risk factors such as smoking, cholecystectomy, cirrhosis, intrahepatic lithiasis, and transplantation should be considered individually by the attending physician for radiological monitoring and incidental discovery of the neoplasm. Lack of timely identification by the attending physician can delay diagnosis, increasing mortality.
Gastric stump neoplasia is defined as a neoplasia that arises in the gastric remnant after at least 5 years of interval from the first gastric resection.
The aim of this study was to analyze 51 patients who underwent total and subtotal gastrectomy and multi-visceral resections in patients with gastric stump cancer.
The hospital records of 51 patients surgically treated for gastric stump cancer between 1989 and 2019 were reviewed. The following data were analyzed: sex, age group, the interval between the first surgery and the diagnosis of gastric stump cancer, location of the ulcer that motivated the gastrectomy, type of reconstruction, tumor resectability, surgery performed, reconstruction of the digestive tract, associated surgical procedures, postoperative complications using the Clavien-Dindo classification, disease staging, and survival.
There were 43 (83.3%) men, with a mean age of 66.9 years. The mean interval between the initial gastrectomy and surgery for the treatment of gastric stump neoplasia was 34.7 years. All had previously undergone Billroth II reconstruction. Most patients underwent total gastrectomy (35 cases – 68.6%), followed by subtotal gastrectomy (6 cases – 11.8%), and the remainder were considered unresectable (10 patients – 19.6%), undergoing jejunostomy for nutritional support. Multi-visceral resections consisted of splenectomies, cholecystectomies, hepatectomies, partial colectomies, pancreatectomies, enterectomies, and nephrectomies. Among the patients who had the lesion resected, the mean follow-up time was 34.2 months (standard deviation: 47.6 months), the overall survival at 3 years was 43.6%, and the survival at 5 years was 29.7%.
The treatment of gastric stump neoplasia is still challenging and difficult, and personalized follow-up strategies should be focused on high-risk patients, offering opportunities for early intervention, better clinical outcomes, and long-term survival.
The use of mesh in the repair of large hiatal hernias is still controversial. One of the most feared adverse events related to the use of mesh is erosion into the esophageal and gastric walls.
To record the endoscopic treatment of mesh that has migrated into the gastric lumen after surgical treatment of hiatal hernia.
The technical option was to wait for the progressive migration of the mesh into the gastric lumen, monitoring with upper digestive endoscopy, with removal by traction at the best time, with the aid of foreign body forceps.
The mesh was completely removed, and the evolution was satisfactory, without complications.
In patients with mesh migration into the stomach who are oligosymptomatic and do not show signs of complications, endoscopic surveillance and subsequent removal of the foreign body can be successfully performed when the mesh is not adhered to the gastric wall, avoiding surgical procedures with high morbidity and mortality.
Hepatectomy is historically associated with higher morbidity and mortality, related to intraoperative blood loss and biliary fistulas. Technological advances and improvements in surgical and anesthetic techniques have led to greater safety in performing these surgeries.
The aim of this study was to analyze morbidity and mortality in patients undergoing hepatectomy.
Retrospective cohort study of patients undergoing liver resections. The type of hepatectomy, indications, need for intraoperative blood transfusion, hospital stay, complications, and postoperative mortality were analyzed.
A total of 48 hepatectomies were performed during the studied period, the most common being 26 (54.16%) major hepatectomies, distributed among 13 (50%) left hepatectomies, 11 (42.30%) right hepatectomies, and 2 (7.70%) others. In total, 24 (45.84%) minor hepatectomies were performed, 11 (50%) mono segmentectomies, and 5 (22.72%) left lateral hepatectomies. The main indications for resection in benign diseases were 6 (12.50%) neotropical hepatic hydatidosis, five (10.41%) intrahepatic lithiasis, and in primary malignancies, 9 (18.75%) hepatocarcinomas. There was no need for an intraoperative blood transfusion. Hospital stays after surgery ranged from 2 to 40 days (average=7 days), and 41 (85.42%) patients went to the ICU in the first 72 h after surgery. In total, 9 (18.75%) patients developed postoperative complications. Overall mortality was 2.08%.
Hepatocellular carcinoma and neotropical hydatidosis were the main diseases with surgical indication, and major hepatectomies were the most performed procedures. Morbidity and mortality were in line with results from major global centers.
Laparoscopic gastrectomy offers advantages in the postoperative period compared to the open approach. Most studies have been performed on distal gastrectomies; however, laparoscopic total gastrectomy (LTG) is not universally accepted. AIM: The aim of this study was to assess the results of LTG, on postoperative morbidity outcomes and long-term survival.
This is a retrospective cohort study from a prospective database of patients who underwent LTG, from 2005 to 2022, due to early and advanced gastric cancer. A totally laparoscopic technique was utilized, and the Roux-en-Y reconstruction was performed in all cases. Postoperative complications and long-term survival were evaluated.
A total of 100 patients were included (men 57, age 64 years, and body mass index 26). A D2 lymphadenectomy was performed in 68 cases. The postoperative hospitalization period was 8 days (6–62 days). Postoperative complications occurred in 26%, with 7% esophago-jejunal anastomosis leak, 4% abdominal collections, and 2% gastrointestinal bleeding. In 7% of cases, the complication was considered Clavien 3 or greater. Operative mortality was 1%. The pathology findings confirmed advanced gastric cancer in 50 cases. The median lymph node count was 38, and surgery was considered R0 in 99%. The median follow-up was 50 months. Overall 5-year survival was 74%. Survival in T1 cases was 95% at 5 years. For stage I, survival was 95%, and for stages II and III, it was 52% and 43%, at 5 years, respectively.
These results support the feasibility and oncological adequacy of minimally invasive total gastrectomy. Postoperative morbidity has an acceptable rate. Long-term survival was in accordance with the disease stage.
Nowdays, more relevant applications of perinatal derivatives, such as amniotic membrane (AM), are emerging in our environment as a source of biomaterials for use in different healing processes. The study of anastomosis healing associated with antimetabolic drugs such as 5-fluorouracil (5-FU) is a potential target of AM.
To evaluate the healing effects of AM in rats treated with 5-FU at a dose of 20 mg/kg on the seventh day of postoperative evolution, regarding the parameters percentage of type I collagen (mature), cell viability, microvascular density and formation of granulation tissue.
Thirty-two Wistar rats were used, submitted to colotomy and colorraphy, separated into four groups of eight, which received different treatments daily, intraperitoneally, until the day of sacrifice: saline solution (C), 20 mg/kg 5-FU, 20 mg/kg 5-FU and AM.
Treatment with 20 mg/kg of 5-FU, on the seventh postoperative day, induced adverse effects on the anastomotic healing process, evidenced by a decrease in the percentage of type I (mature) collagen, cell viability, microvascular density, fibrin-leukocyte scab formation and angiofibroblast proliferation; the use of AM under these conditions induced an improvement in the percentage of type I (mature) collagen.
Treatment with 20 mg/kg of 5-FU on the seventh postoperative day induced adverse effects on the anastomotic healing process, and the use of AM under these conditions induced an improvement in the percentage of type I (mature) collagen.
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