Alexandre Coutinho Teixeira de Freitas

Donor Complications Including the Report of One Death in Right-Lobe Living-Donor Liver Transplantation

Background/Aims: Our objective is to assess donor complications in all right hepatic lobe living-donor liver transplantation (LDLT) at our center. Methods: Of a total of 352 liver transplantations performed, 60 were right-lobe LDLT. Most donors (88.3%) were related to the recipients. Results: Mean hospital stay was 5.4 8 0.6 days. No complications occurred due to preoperative evaluation. Most donors received one or two units of autologous blood transfusion. Only 5 (8.3%) needed nonautologous blood transfusion. Most complications were minor and treated conservatively. Bile leaks from the cut surface of the liver occurred in 5 donors (8.3%). Two patients had potentially fatal complications: perforated duodenal ulcer and portal vein thrombosis (PVT). The donor with perforated ulcer developed septicemia and multiple organ failure. He was discharged from the hospital with hemiparesis due to cerebral ischemia. The patient with PVT remained asymptomatic and the portal vein was recanalized by the 3rd postoperative month. One donor died in the immediate postoperative period of cardiac arrest due to cardiac arrhythmia. Conclusion: Right hepatectomy for LDLT may be associated with significant morbidity, including death and it should be performed only by surgeons with great experience.

The impact of bariatric surgery on nonalcoholic fatty liver disease.

Purpose of reviewTo analyze the effects of bariatric surgery on nonalcoholic fatty liver disease by reviewing the most important and recent studies. Recent findingsThe prevalence of obesity has increased dramatically over the last decades. Comorbidities related to obesity, such as nonalcoholic fatty liver disease are also increasing. Nonalcoholic fatty liver disease is a progressive disease with potential evolution to liver cirrhosis and hepatocellular carcinoma. Overweight patients who have nonalcoholic fatty liver disease should be considered for a weight loss program; however, long-term result with dietary interventions and drug therapy has been disappointing. Bariatric surgery is effective in promoting long-term weight loss in morbidly obese patients with control of comorbidities, especially those associated with the metabolic syndrome. On the basis of the early experience with extensive intestinal bypass, it was believed that rapid weight loss could cause liver damage. In contrast, recent prospective and retrospective observational studies and case series have demonstrated that bariatric surgery is well tolerated and is associated with nonalcoholic fatty liver disease regression in a significant number of patients. SummaryThere is good level of evidence that bariatric surgery is associated with nonalcoholic fatty liver disease regression in morbidly obese patients.

Opinião e conhecimento da população da cidade de curitiba sobre doação e transplante de órgãos

OBJECTIVE: To determine the opinion and knowledge of the population of Curitiba about organ donation and transplantation. METHODS: The opinion and knowledge about organ donation and transplantation of 1,000 subjects over 18 years of age were determined. The subjects responded to a questionnaire of 20 queries. Respondents had age, gender, social-economic, and education distributions similar to those of the Brazilian population, as defined by the Brazilian Institute of Geography and Statistics (IBGE). RESULTS: Eighty-seven percent of respondents were in favor of organ donation. There was no difference in the percentage of respondents in favor of donation in relation to gender, marital status, religion, and income. The main reasons in favor of donation were to save life, to help other persons and to donate life. The main reasons against donation were distrust towards medicine or the Brazilian transplantation organization, the existence of organ sale, and fear of body mutilation. Most respondents believed that wealthy people have a better chance to receive an organ than poor people, that sales of organs exists in Brazil, and that misdiagnosis of brain death may occur. CONCLUSION: Most respondents are in favor of organ donation and have a good knowledge of organ donation and transplantation. The majority distrusts Brazilian organization of organ distribution and brain death diagnosis.

Acao do extrato de Jatropha gossypiifolia L. (piao roxo) na cicatrizacao de anastomose colonica: estudo experimental em ratos

INTRODUCTION: Phytotherapy has been drawing interest from the scientific community regarding its potential wound healing properties. There are few studies available that present a correct scientific methodology and, therefore, phytotherapy remains an open field for further research. PURPOSE: To evaluate the effects of Jatropha gossypiifolia L. (bellyache bush) on the healing of colonic anastomosis in rats. METHODS: Forty Wistar rats were subjected to a complete section of the colon, that was soon sutured with eight separate stitches using monofilament polipropilene 6-0. Randomly, the animals were divided into control group (CG), with 20 rats, which were injected with 0.9% sodium chloride solution intraperitoneally (1mL/kg) and Jatropha group (JG), also with 20 rats, which were injected with Jatropha gossypiifolia L. alcoholic extract intraperitoneally (1mL/kg). Each of the groups was subdivided into two subgroups of ten rats, according to the sacrifice date, third and seventh days (CG3/ CG7 and JG3/ JG7). After sacrifice, the segment of the colon containing 1cm proximal and distal to the site of anastomosis was removed and subjected to the pressure test with air insuflation. This segment was then opened and a 1.0 x 0.5cm part was removed and placed under 10% formaldehyde for histological analysis with hematoxylin-eosin and Massons trichrome stainings. RESULTS: The evaluation of the pressure rupture test demonstrated statistical significance regarding the sacrifice date. On the third day, the average pressure of the CG (25,4mmHg) and the JG (76,4mHg) revealed p = 0.013, and on the seventh day, the average pressure of the CG (187,3 mmHg.) and the JG (135,1 mmHg.) revealed p = 0.014. When assessing the microscopic variables among the groups of the 3rd day, only the variables edema and polymorphonuclear cells did not show statistical differences. On the 7th day, all of the variables assessed demonstrated significant differences. CONCLUSIONS: Regarding mechanical resistance, there was a difference in resistance between the JG3 and the CG3, and a shift of resistance when comparing the JG7 and CG7, which suggests a weakening of the Jatropha effect at a later stage of healing. The histological evaluation revealed an improvement of the acute inflammatory process in the JG3 when compared to the CG3, which was even more intense during the chronic stage, when the two groups are compared on the seventh day. The histological study of the inflammatory process, in general, showed a favorable effect to the Jatropha group compared to the control group.INTRODUCTION Phytotherapy has been drawing interest from the scientific community regarding its potential wound healing properties. There are few studies available that present a correct scientific methodology and, therefore, phytotherapy remains an open field for further research. PURPOSE To evaluate the effects of Jatropha gossypiifolia L. (bellyache bush) on the healing of colonic anastomosis in rats. METHODS Forty Wistar rats were subjected to a complete section of the colon, that was soon sutured with eight separate stitches using monofilament polypropylene 6-0. Randomly, the animals were divided into control group (CG), with 20 rats, which were injected with 0.9% sodium chloride solution intraperitoneally (1 mL/kg) and Jatropha group (JG), also with 20 rats, which were injected with Jatropha gossypiifolia L. alcoholic extract intraperitoneally (1 mL/kg). Each of the groups was subdivided into two subgroups of ten rats, according to the sacrifice date, third and seventh days (CG3/ CG7 and JG3/ JG7). After sacrifice, the segment of the colon containing 1cm proximal and distal to the site of anastomosis was removed and subjected to the pressure test with air insulation. This segment was then opened and a 1.0 x 0.5 cm part was removed and placed under 10% formaldehyde for histological analysis with hematoxylin-eosin and Massons trichrome stainings. RESULTS The evaluation of the pressure rupture test demonstrated statistical significance regarding the sacrifice date. On the third day, the average pressure of the CG (25.4 mmHg) and the JG (76.4 mmHg) revealed p = 0.013, and on the seventh day, the average pressure of the CG (187,3 mmHg.) and the JG (135.1 mmHg.) revealed p = 0.014. When assessing the microscopic variables among the groups of the 3rd day, only the variables edema and polymorphonuclear cells did not show statistical differences. On the 7th day, all of the variables assessed demonstrated significant differences. CONCLUSIONS Regarding mechanical resistance, there was a difference in resistance between the JG3 and the CG3, and a shift of resistance when comparing the JG7 and CG7, which suggests a weakening of the Jatropha effect at a later stage of healing. The histological evaluation revealed an improvement of the acute inflammatory process in the JG3 when compared to the CG3, which was even more intense during the chronic stage, when the two groups are compared on the seventh day. The histological study of the inflammatory process, in general, showed a favorable effect to the Jatropha group compared to the control group.

Effect of watery extract of Orbignya phalerata (babassu) in the gastric healing in rats: morfologic and tensiometric study

ABSTRACT Introduction : The large use of plants in the prevention and treatment of different diseases is a milenar practice. In Brazil due to it’s rich flora there is a huge material for research and use in popular medicine. The babassu ( Orbignya phalerata ) is a native tree from North of the Brazil and has a high concentration at the State of Maranhao. The powder of it’s mesocarp is known as amid, and has been used as meal and medication due to the known activity against antiflammatory reaction, pain, pyrexia and immunomodulation. Purpose: To analyze the effect of mesocarp of Orbignya phalerata (babassu) in gastric wound healing in rats under morphologic and tensiometric aspects. Method: Forty Wistar rats, male, adults were submitted to a longitudinal incision of 1 cm in the gastric body and sutured with separated stitches of polypropilene 6.0. After this common procedure the animals were allocated in the aleatory way in two groups Orbignya (GO) and Control (GC) with 20 animals each one. In the GO was used intraperitoneal doses of 50mg/kh of

Qualidade de vida do doador após transplante hepático intervivos

RACIONAL: A qualidade de vida do doador apos transplante hepatico intervivos ainda nao foi avaliada em nosso meio. OBJETIVO: Avaliar a qualidade de vida do doador apos transplante hepatico intervivos. METODOS: De um total de 300 transplantes hepaticos, 51 foram de doadores vivos. Doadores com seguimento menor do que 6 meses e os que nao quiseram participar do estudo foram excluidos. Os doadores responderam a um questionario de 28 perguntas abordando os varios aspectos da doacao, sendo tambem avaliados dados demograficos e clinicos dos mesmos. RESULTADOS: Trinta e sete doadores aceitaram participar do estudo. Destes, 32 eram parentes de primeiro ou de segundo grau do receptor. O esclarecimento sobre o carater voluntario da doacao foi adequado para todos pacientes. Apenas um (2%) nao doaria novamente. A dor pos-operatoria foi pior do que o esperado para 22 doadores (59%). O retorno as atividades normais ocorreu em menos de 3 meses para 21 doadores (57%). Vinte e um doadores (57%) tiveram perda financeira com a doacao devido a gastos com medicamentos, exames, transporte ou perda de rendimentos. Trinta e tres (89%) nao tiveram modificacao ou limitacao na sua vida apos a doacao. Os aspectos mais negativos da doacao foram a dor pos-operatoria e a presenca de cicatriz cirurgica. A maioria das complicacoes pos-operatoria foi resolvida com o tratamento clinico, mas complicacoes graves ou potencialmente fatais ocorreram em dois pacientes. CONCLUSOES: A maioria dos doadores apresentou boa recuperacao e retornou completamente as suas atividades normais poucos meses apos a doacao. O aspecto mais negativo da doacao foi a dor pos-operatoria.

The impact of the model for end-stage liver disease (MELD) on liver transplantation in one center in Brazil

CONTEXT Presently the MELD score is used as the waiting list criterion for liver transplantation in Brazil. In this method more critical patients are considered priority to transplantation. OBJECTIVE To compare the results of liver transplantation when the chronologic waiting list was the criterion for organ allocation (pre-MELD era) with MELD score period (MELD era) in one liver transplantation unit in Brazil. METHODS The charts of the patients subjected to liver transplantation at the Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil, were reviewed from January of 2001 to August of 2008. Patients were divided into two groups: pre-MELD era and MELD era. They were compared in relation to demographics of donors and receptors, etiology of cirrhosis, cold and warm ischemia time, presence of hepatocellular carcinoma, MELD score and Child-Pugh score and classification at the time of transplantation, units of red blood cells transfused during the transplantation, intensive care unit stay, total hospital stay and 3 month and 1 year survival. RESULTS Initially, 205 liver transplantations were analyzed. Ninety four were excluded and 111 were included: 71 on the pre-MELD era and 40 on the MELD era. The two groups were comparable in relation to donors and receptors age and sex, etiology of cirrhosis and cold and warm ischemia time. The receptors of the MELD era had more hepatocellular carcinoma than those of the pre-MELD era (37.5% vs 16.9%). Patients with hepatocellular carcinoma had less advanced cirrhosis on both eras. The MELD score was the same on both eras. Excluding the cases of hepatocellular carcinoma, MELD era score was higher than pre-MELD score (18.2 vs 15.8). There were an increased number of transplants on Child-Pugh A and C and a decreased number on Child-Pugh B receptors on MELD era. Both eras had the same need of red blood cells transfusion, intensive care unit stay and hospital stay. Also, 3 month and 1 year survival were the same: 76% and 74.6% on pre-MELD era and 75% and 70.9% on MELD era. CONCLUSION In our center, after the introduction of MELD score as the priority criterion for liver transplantation there were an increased number of transplants with hepatocellular carcinoma. Excluding these patients, the receptors were operated upon with more advanced cirrhosis. Nevertheless the patients had the same need for red blood cells transfusion, intensive care unit and hospital stay and 3 months and 1 year survival.

Insulin-like growth factor I correlates with MELD and returns to normal level after liver transplantation

BACKGROUND Insulin-like growth factor I (IGF-I) is produced almost entirely by the liver and is the main promoter of anabolic growth hormone (GH) effects on protein, carbohydrate, and lipid metabolism. IGF-I is significantly decreased in patients with liver cirrhosis. Our objective was to determine the relationship between circulating IGF-I and MELD (Model for End-stage Liver Disease) in cirrhotics subjected to orthotopic liver transplantation (OLT). We also assessed the changes of IGF-I and its major binding protein (IGF-binding protein-3 or IGFBP-3) after OLT. MATERIAL AND METHODS In a prospective study, serum levels of IGF-I and IGFBP-3 of 25 male adult patients with end-stage liver disease were measured 2 to 4 hours before and 6 months after orthotopic liver transplantation. Seven age-matched healthy male volunteers with normal liver enzymes, albumin, and prothrombin time served as controls. MELD was determined on the day of OLT. For this analysis, extra points were not added for patients with hepatocarcinoma. RESULTS The cirrhotic group had significantly lower IGF-I (46.7±21.6 ng/mL) and IGFBP-3 (1.0±0.9 ng/mL) levels in the pre-transplant period compared with the controls (208.6±76.5 ng/mL and 4.62±0.93 ng/mL, respectively) (p<0.05). There was a negative correlation between IGF-I or IGFBP-3 and MELD (p<0.001) (ß=-1.750; standard error =2.5054 and ß=-0.038; standard error <0.0001, respectively). IGF-I e IGFBP-3 increased to normal levels after OLT (207.7±82.8 and 4.14±1.1 ng/mL, respectively) (p<0.001). CONCLUSIONS Low levels of IGF-I and IGFBP-3 observed in patients with advanced liver cirrhosis are corrected after OLT. IGF-I and IGFBP-3 correlate negatively with MELD.

Doença hepática não-alcoólica: evolução após derivação gastrojejunal em Y-de-Roux pela técnica de fobi-capella

BACKGROUND: Nonalcoholic fatty liver disease is highly prevalent among morbidly obese patients and can progress from steatosis to steatohepatitis and chronic liver disease. AIM: To determine the effect of gastric bypass operation in the incidence of fatty liver disease and associated co-morbidities in morbidly obese patients. METHODS: Patients were prospectively evaluated in the pre-operative period and after at least 6 months after operation. We analysed: antropometric data, co-morbidities, use of medications, cholesterol and triglycerides levels, liver tests and incidence of nonalcoholic fatty liver disease. All patients with abnormal liver tests were subjected to per-operative liver biopsy. RESULTS: Twenty eight patients with nonalcoholic fatty liver disease with a mean body mass index of 42 ± 4 kg/m2 were evaluated. Twenty five patients had 59 co-morbidities and the most frequent were: elevated triglycerides (n = 23), elevated cholesterol (n = 13) and elevated blood pressure (n = 11). Biopsy was done in 22 patients: 10 presented moderate steatosis, 5 mild steatosis and 7 steatohepatitis. After follow-up of 230 days in average they presented weight excess loss of 64%, body mass index reduction to 29,6 ± 3 kg/m2 and 21 co-morbidities in 13 patients. There was a significant decrease in the number of patients with elevated triglycerides, elevated cholesterol, elevated blood pressure and in the incidence of nonalcoholic fatty liver disease. CONCLUSION: The weight loss secondary to the gastric bypass is associated with decrease in the incidence of nonalcoholic fatty liver disease and other co-morbidities.

TESTOSTERONE CHANGES IN PATIENTS WITH LIVER CIRRHOSIS BEFORE AND AFTER ORTHOTOPIC LIVER TRANSPLANTATION AND ITS CORRELATION WITH MELD

CONTEXT Hypogonadism is a common clinical situation in male patients with liver cirrhosis. OBJECTIVES The aim of the present study was to evaluate the effects of orthotopic liver transplantation on testosterone, free testosterone and sex hormone-binding globulin in male with advanced liver disease and also to determine the relationship of these changes with Model for End-stage Liver Disease (MELD) score. METHODS In a prospective study, serum levels of testosterone, free testosterone and sex hormone-binding globulin of 30 male adult patients with end-stage liver disease were measured 2 to 4 hours before and 6 months after orthotopic liver transplantation. RESULTS Total testosterone levels increased after orthotopic liver transplantation and the number of patients with normal testosterone levels increased from 18 to 24. Free testosterone mean level in the pre-transplant group was 7.8 pg/mL and increased to 11.5 pg/mL (P = 0.10) and sex hormone-binding globulin level decreased after orthotopic liver transplantation returning to normal levels in MELD ≤ 18 - group (A) (P<0.05). CONCLUSIONS Serum level changes of testosterone, free testosterone and sex hormone-binding globulin are more pronounced in cirrhotic males with MELD ≤ 18. Serum levels of testosterone and free testosterone increase and serum levels of sex hormone-binding globulin decrease after orthotopic liver transplantation.