Although the presence of synchronous colorectal liver metastases (CRLM) represents an important prognostic factor for recurrence-free survival (RFS) and overall survival (OS), the definitions of synchronicity are variable in the literature, including metastases at the time of diagnosis, or even before the diagnostic of the primary site of colorectal cancer (CRC), until either six or 12 months after the time of diagnosis, according to the author of each study. Simultaneous approaches to treat CRC and CRLM seem to be safe for patients carefully selected without jeopardizing oncologic outcomes, with similar complication rates, shorter hospital length of stay, and operation times even for major hepatectomies. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged, and both performance status and the presence of symptoms play important roles in the treatment sequence, perhaps avoiding two high-risk procedures at the same time.
The presence of synchronous colorectal liver metastases represents an important prognostic factor for recurrence-free survival and overall survival, the definitions of synchronicity are variable in the literature, including metastases at the time of diagnosis, or even before the diagnostic of the primary site of colorectal cancer, and until either six or 12 months after the time of diagnosis, according to the authors of the studies.
Simultaneous approaches to treat colorectal cancer and colorectal liver metastases seem to be safe for patients carefully selected without jeopardizing oncologic outcomes, with similar complication rates, shorter length of stay and operation times even for major hepatectomies. However, there is no consensus about the optimal timing to approach the primary tumor and colorectal liver metastases, whether simultaneously or staged, and both performance status and presence of symptoms play important roles in the treatment sequence, perhaps avoiding two high-risk procedures at the same time
Although the presence of synchronous colorectal liver metastases (CRLM) represents an important prognostic factor for recurrence-free survival (RFS) and overall survival (OS), the definitions of synchronicity are variable in the literature, including metastases at the time of diagnosis, or even before the diagnostic of the primary site of colorectal cancer (CRC), until either six or 12 months after the time of diagnosis, according to the author of each study. Simultaneous approaches to treat CRC and CRLM seem to be safe for patients carefully selected without jeopardizing oncologic outcomes, with similar complication rates, shorter hospital length of stay, and operation times even for major hepatectomies. However, there is no consensus about the optimal timing to approach the primary tumor and CRLM, whether simultaneously or staged, and both performance status and the presence of symptoms play important roles in the treatment sequence, perhaps avoiding two high-risk procedures at the same time.
Surgery is associated with a high risk for morbidity and mortality, particularly when performed in critical patients requiring intensive care unit (ICU) admission.
The aim of this study was to investigate risk factors associated with adverse outcomes in a large cohort of patients admitted to a single-center ICU after abdominal surgery.
All patients admitted to a surgical ICU for postoperative care, from January 2016 to December 2022, were retrospectively evaluated. Data concerning demographics and clinical and perioperative variables were compared to in-hospital mortality.
A total of 1,717 patients (1,096 women, mean age: 61±17 years) were evaluated. Most of the patients underwent colorectal (n=499), pancreatic (n=148), biliary tract (n=147), and gastric surgeries (n=145); liver resection (n=131); and several gynecological or obstetric procedures (n=250). Only 52.3% of these surgical procedures were elective. The mean Charlson Comorbidity Index (CCI) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 4.4±2.8 and 10.1±5.6, respectively. Mortality was observed in 158 (9.2%) patients. Age (70.4±14.3 vs. 60.6±17.1 years in survivors, p=0.002), CCI (6.1±2.5 vs. 4.3±2.8 in survivors, p=0.005), type of surgery (13.6% in emergent/urgent vs. 5.5% in elective surgeries, p<0.001), and APACHE II score (16.7±8.4 vs. 9.4±4.7 in survivors, p<0.0001) were associated with mortality on univariate analysis, but only CCI, type of surgery, and APACHE II score were independently correlated with a higher risk of death on multivariate analysis.
Mortality after abdominal surgery in patients requiring postoperative ICU support is less than 10% nowadays, and it is independently associated with urgent or emergent surgeries, disease severity, and comorbidity.
The development of surgical techniques, chemotherapy, biological agents, and multidisciplinary approaches have made patients with unresectable colorectal liver metastases eligible for surgery. Many strategies have been developed to allow patients for surgical resection (percutaneous portal vein embolization, liver venous deprivation, parenchyma-sparing liver surgery, reverse strategy, associating liver partition and portal vein ligation for staged hepatectomy, and liver transplantation), the only form of disease control and curative treatment.
Umbilical and epigastric hernias are among the most common hernias of the abdominal wall; however, there is a lack of standardization for their treatment.
To clarify the controversies regarding therapeutic possibilities, indications, and surgical techniques for umbilical and epigastric hernia repair.
A systematic review and qualitative analysis of randomized clinical trials published in the last 20 years, involving adults (aged 18 years and over) with umbilical and/or epigastric hernias, was performed by systematically searching the PubMed/Medline, Cochrane, SciELO, and LILACS databases. The risk of bias in individual studies was assessed using the Cochrane Risk of Bias Tool.
Initially, 492 studies were selected and, subsequently, 15 randomized controlled clinical trials were chosen that met the inclusion criteria and underwent full reading and qualitative analysis, considering possible bias.
This review concluded that it is evident the superiority of the use of meshes in the repair of epigastric/primary umbilical hernias with a defect larger than 1 cm, even in certain emergency situations. However, suture repair is a good option for patients with a defect smaller than 1 cm. In the laparoscopic approach, recent evidence points towards possible superiority in fixation with fibrin sealant, and fascial defect closure is recommended. In addition, due to a scarcity of randomized controlled trials with low risk of bias, further studies are needed on types, positioning and fixation techniques, as well as the real role of video-assisted laparoscopic surgery in the correction of hernias, especially umbilical.
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.
Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient’s desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.
Colorectal cancer (CRC) is the most common malignancy of the gastrointestinal tract and the third most common type of cancer worldwide. The COVID-19 pandemic, during the years 2020 and 2022, increased the difficulties in offering adequate early diagnosis and treatment to CRC patients worldwide. During this period, it was only possible to treat patients who evolved with complications, mainly intestinal obstruction and perforation.
To assess the impact of the COVID-19 pandemic on the treatment of patients with CRC.
A review of data from a total of 112 patients undergoing emergency surgical treatment due to complications of CRC was carried out. Of these, 78 patients underwent emergency surgery during the COVID-19 pandemic (2020/2021), and 34 were treated before the pandemic (2018/2019). Ethnic aspects, clinical symptoms, laboratory tests, histopathological variables, intra and postoperative complications, and 90-day postoperative follow-up were compared between the two groups.
Between the years 2018 and 2019, 79.4% (27/34) of patients had intestinal obstruction, while 20.6% (7/34) had intestinal perforation. During the period of the COVID-19 pandemic (2020/2021), 1.3% (1/78) of patients underwent surgery due to gastrointestinal bleeding, 6.4% (5/78) due to intestinal perforation, and 92.3% (72/78) due to intestinal obstruction. No statistically significant differences were recorded between the two groups in ethnic aspects, laboratory tests, type of complications, number of lymph nodes resected, compromised lymph nodes, TNM staging, pre or intraoperative complications, length of stay, readmission, or mortality rate. When considering postoperative tumor staging, among patients operated on in 2018/2019, 44.1% were classified as stage III and 38.2% as stage IV, while during the pandemic period, 28.2% presented stage III and 51.3% stage IV, also without a statistically significant difference between the two periods. Patients operated on during the pandemic had higher rates of vascular, lymphatic and perineural invasion.
The COVID-19 pandemic increased the rate of complications related to CRC when comparing patients treated before and during the pandemic. Furthermore, it had a negative impact on histopathological variables, causing worse oncological prognoses in patients undergoing emergency surgery.
Metastatic gastric cancer traditionally hinders surgical treatment options, confining them to palliative procedures. The presence of metastases in these tumors is classified as M1, irrespective of their characteristics, quantity, or location. However, oligometastatic disease emerged as an intermediate state between localized and widely disseminated cancer. It exhibits diverse patterns based on metastatic disease extent, type, and location. Adequately addressing this distinctive metastatic state necessitates tailored strategies that surpass the realm of palliative care. Differentprimary tumor types present discernible scenarios of oligometastatic disease, including preferred sites of occurrence and chronological progression. Due to the novelty of this theme and the heterogeneity of the disease, uncertainties still exist, and the ability to provide confident guidelines is challenging. Currently, there are no effective predictors to determine the response and provide clear indications for surgical interventions and systemic treatments in oligometastatic disease. Treatment decisions are commonly based on apparent disease control by systemic therapies, with a short observation period and imaging assessments. Nonetheless, the inherent risk of misinterpretation remains a constant concern. The emergence of novel technologies and therapeutic modalities, such as immunotherapy, cellular therapy, and adoptive therapies, holds the potential to reshape the landscape of surgical treatment for the oligometastatic disease in gastric cancer, expanding the surgeon’s role in this multidisciplinary approach. Prospective tools for patient selection in oligometastatic gastric cancer are being explored. Using non-invasive, cost-effective, widely available imaging techniques that provide real-time information may revolutionize medical practice, ensuring precision medicine accessibility, even in resource-constrained small healthcare facilities. Incorporating molecular classifications, liquid biopsies, and radiomic analysis in a complementary protocol will augment patient selection precision for surgical intervention in oligometastasis. Hopefully, these advancements will render surgeries unnecessary in many cases by providing highly effective alternative treatments.
Liver transplantation is performed at large transplant centers worldwide as a therapeutic intervention for patients with end-stage liver diseases.
To analyze the outcomes and incidence of liver transplantation performed at the University of São Paulo and to compare those with the State of São Paulo before and after adoption of the Model for End-Stage Liver Disease (MELD) score.
Evaluation of the number of liver transplantations before and after adoption of the MELD score. Mean values and standard deviations were used to analyze normally distributed variables. The incidence results were compared with those of the State of São Paulo.
There was a high prevalence of male patients, with a predominance of middle-aged. The main indication for liver transplantation was hepatitis C cirrhosis. The mean and median survival rates and overall survival over ten and five years were similar between the groups (p>0.05). The MELD score increased over the course of the study period for patients who underwent liver transplantation (p>0.05). There were an increased number of liver transplants after adoption of the MELD score at this institution and in the State of São Paulo (p<0.001).
The adoption of the MELD score led to increase the number of liver transplants performed in São Paulo.
Desenvolvido por Surya MKT