Aljamir Duarte Chedid

Histoplasmosis presenting as addisonian crisis in an immunocompetent host

A 71-year-old man with presumptively treated pulmonary tuberculosis ten years earlier and previous alcoholism presented with adrenal insufficiency. HIV serology was negative. A computerized tomography scan of the abdomen showed enlarged right adrenal. He recovered after emergency treatment with hydrocortisone IV. Right adrenalectomy was performed. Histoplasmosis was diagnosed and the patient was treated with itraconazole, corticosteroid replacement, and discharged with good health.

Fatores prognósticos na ressecção de metástases hepáticas de câncer colorretal

AIM: To determine the impact of prognostic factors on survival of patients with metastases from colorectal cancer that underwent liver resection. METHODS: The records of 28 patients that underwent liver resection for metastases from colorectal cancer between April 1992 and September 2001 were retrospectively analyzed. Thirty-eight resections were performed (more than one resection in eight patients and two patients underwent re-resections). The primary tumor was resected in all the patients. A screening protocol for liver metastases including clinical examinations every three months, ultrassonography and CEA level until 5 years of follow-up and after every 6 months, was applied. The prognostic factors analyzed regarding the impact on survival were: Dukes C stage of primary tumor, size of metastasis >5 cm, a disease-free interval from primary tumor to metastasis 100 ng/mL, resection margins < 1 cm and extrahepatic disease. The Kaplan-Meier curves, log rank and Cox regression were used for the statistical analysis. RESULTS: Perioperative morbidity and mortality were 39.3% and 3.6%, respectively. The 5-year survival rate was 35%. The independent prognostic factors were: disease-free interval from primary tumor to metastasis < 1 year and extrahepatic disease. CONCLUSIONS: The liver resection for metastases from colorectal cancer is a safe procedure with more than 30% 5-year survival. Disease-free interval from primary tumor to metastasis < 1 year and extrahepatic disease were independent prognostic factors.

Divertículo único do ceco: experiência de um hospital geral brasileiro

BACKGROUND Cecal diverticulitis is a rare condition, specially in western people. Its importance concerns of being part of the differential diagnosis of acute appendicitis and ulcerated cecal carcinoma. AIM To present the experience of southern Brazilian general hospital in the treatment of cecal diverticulitis. MATERIAL AND METHODS We present four cases of single inflamed cecal diverticulum. One was diagnosed by pre-operatively computer tomography and was treated medically without complications. The other three cases were diagnosed during operation and treated by right hemicolectomy and ileotransverse anastomosis. RESULTS There were no deaths or complications. When cecal diverticulitis is pre-operatively diagnosed it may be treated medically. We preclude laparotomy when the diagnosis is uncertain. CONCLUSION We recommend radical surgical management when the diagnosis is made during operation.

Development of clinical celiac disease after pancreatoduodenectomy: a potential complication of major upper abdominal surgery

BackgroundCeliac disease is a gluten-induced disease of global malabsorption. There is a subset of patients with celiac disease who are free of major symptoms but who have typical damage to the intestinal mucosa (silent disease). We present the case of a 50-year-old white woman with no clinical symptoms of celiac disease who developed diarrhea and weight loss 12 weeks after a pancreatoduodenectomy for ampullary cancer.MethodsMicrobiological and biochemical examination of the feces did not provide clues useful to diagnosis, and diarrhea was not affected by pancreatic enzyme replacement or administration of antiperistaltic drugs.Results Review of the pathologic specimen and blood tests were compatible with celiac disease.ConclusionThis clinical scenario illustrates that subclinical celiac disease may be an underdiagnosed cause of malabsorption after major upper gastrointestinal surgery and should be considered in the differential diagnosis of diarrhea after pancreatoduodenectomy.

First Report of Human Pancreas Transplantation Using IGL-1 Preservation Solution: A Case Series.

I Georges Lopez preservation solution (IGL-1) is an extracellular type of preservation solution that has lesser viscosity and lower potassium concentration than the criterion of University of Wisconsin preservation solution (UW). Institute Georges Lopez-1 preservation solution has been used for preservation of human kidney and liver allografts, resulting in transplant outcomes that are similar to those obtained with UW. Although IGL-1 has been used successfully for preservation of human islet cells prior transplantation, and also for experimental pancreas transplantation, no previous report of human pancreas transplantation using IGL-1 was found in the medical literature. From February to October 2015, 5 consecutive simultaneous pancreas and kidney transplants were performed using IGL-1 preservation solution at our institution (Table 1). Procurement operations and pancreas transplantswere performed by a same surgeon (Chedid, M.F.). After cross clamping, 5 L of IGL-1 was infused through deceased donors aorta, and 1 Lwas infused through inferiormesenteric vein. Intravenous

Transarterial Embolization and Percutaneous Ethanol Injection as an Effective Bridge Therapy before Liver Transplantation for Hepatitis C-Related Hepatocellular Carcinoma

Background. Transarterial chemoembolization alone or in association with radiofrequency ablation is an effective bridging strategy for patients with hepatocellular carcinoma awaiting for a liver transplant. However, cost of this therapy may limit its utilization. This study was designed to evaluate the outcomes of a protocol involving transarterial embolization, percutaneous ethanol injection, or both methods for bridging hepatocellular carcinomas prior to liver transplantation. Methods. Retrospective review of all consecutive adult patients who underwent a first liver transplant as a treatment to hepatitis C-related hepatocellular carcinoma at our institution between 2002 and 2012. Primary endpoint was patient survival. Secondary endpoint was complete tumor necrosis. Results. Forty patients were analyzed, age 58 ± 7 years. There were 23 males (57.5%). Thirty-six (90%) out of the total 40 patients were within Milan criteria. Complete necrosis was achieved in 19 patients (47.5%). One-, 3-, and 5-year patient survival were, respectively, 87.5%, 75%, and 69.4%. Univariate analysis did not reveal any variable to impact on overall patient survival. Conclusions. Transarterial embolization, ethanol injection, or the association of both methods followed by liver transplantation comprises effective treatment strategy for hepatitis C-related hepatocellular carcinoma. This strategy should be adopted whenever transarterial chemoembolization and/or radiofrequency ablation are not available options.

ESTIMATING BASAL ENERGY EXPENDITURE IN LIVER TRANSPLANT RECIPIENTS: THE VALUE OF THE HARRIS-BENEDICT EQUATION

ABSTRACT Background: Reliable measurement of basal energy expenditure (BEE) in liver transplant (LT) recipients is necessary for adapting energy requirements, improving nutritional status and preventing weight gain. Indirect calorimetry (IC) is the gold standard for measuring BEE. However, BEE may be estimated through alternative methods, including electrical bioimpedance (BI), Harris-Benedict Equation (HBE), and Mifflin-St. Jeor Equation (MSJ) that carry easier applicability and lower cost. Aim: To determine which of the three alternative methods for BEE estimation (HBE, BI and MSJ) would provide most reliable BEE estimation in LT recipients. Methods: Prospective cross-sectional study including dyslipidemic LT recipients in follow-up at a 735-bed tertiary referral university hospital. Comparisons of BEE measured through IC to BEE estimated through each of the three alternative methods (HBE, BI and MSJ) were performed using Bland-Altman method and Wilcoxon Rank Sum test. Results: Forty-five patients were included, aged 58±10 years. BEE measured using IC was 1664±319 kcal for males, and 1409±221 kcal for females. Average difference between BEE measured by IC (1534±300 kcal) and BI (1584±377 kcal) was +50 kcal (p=0.0384). Average difference between the BEE measured using IC (1534±300 kcal) and MSJ (1479.6±375 kcal) was -55 kcal (p=0.16). Average difference between BEE values measured by IC (1534±300 kcal) and HBE (1521±283 kcal) was -13 kcal (p=0.326). Difference between BEE estimated through IC and HBE was less than 100 kcal for 39 of all 43patients. Conclusions: Among the three alternative methods, HBE was the most reliable for estimating BEE in LT recipients.

HEPATOCELLULAR CARCINOMA: DIAGNOSIS AND OPERATIVE MANAGEMENT

ABSTRACT Introduction: Hepatocellular carcinoma is an aggressive malignant tumor with high lethality. Aim: To review diagnosis and management of hepatocellular carcinoma. Methods: Literature review using web databases Medline/PubMed. Results: Hepatocellular carcinoma is a common complication of hepatic cirrhosis. Chronic viral hepatitis B and C also constitute as risk factors for its development. In patients with cirrhosis, hepatocelular carcinoma usually rises upon malignant transformation of a dysplastic regenerative nodule. Differential diagnosis with other liver tumors is obtained through computed tomography scan with intravenous contrast. Magnetic resonance may be helpful in some instances. The only potentially curative treatment for hepatocellular carcinoma is tumor resection, which may be performed through partial liver resection or liver transplantation. Only 15% of all hepatocellular carcinomas are amenable to operative treatment. Patients with Child C liver cirrhosis are not amenable to partial liver resections. The only curative treatment for hepatocellular carcinomas in patients with Child C cirrhosis is liver transplantation. In most countries, only patients with hepatocellular carcinoma under Milan Criteria are considered candidates to a liver transplant. Conclusion: Hepatocellular carcinoma is potentially curable if discovered in its initial stages. Medical staff should be familiar with strategies for early diagnosis and treatment of hepatocellular carcinoma as a way to decrease mortality associated with this malignant neoplasm.

Signet-ring cell hilar cholangiocarcinoma: case report.

A 66-year-old caucasian woman was admitted with a 40-day history of fatigue, anorexia, jaundice, itching and pale stools. She had undergone external percutaneous transhepatic drainage and had been treated for cholangitis with antibiotics. The patient had no palpable masses and her past medical history was unremarkable. Total bilirubin and liver enzymes were mildly elevated, and CBC was normal. Abdominal computed tomography showed a 4.0 x 0.5 cm tumor on the confluence of the right and left hepatic bile ducts with moderately dilated intrahepatic ducts. It also revealed a 2 cm tumor in the left kidney. Additional workup was negative for metastases. Laparotomy was performed and revealed a hardened mass involving the common bile duct from above the implantation of the cystic duct to the confluence of the right and left hepatic ducts. Resection of the biliary tree was then carried out from the supraduodenal portion of the common bile duct to the first 2 cm of the right and left hepatic ducts, with en-bloc regional lymphadenectomy. A Roux-en-Y jejunal loop was taken to the hepatic hilum and right, left and caudate bile ducts were sewn to a single jejunal loop. Macroscopic exam of the bile duct tumor revealed a 5.5x0.8cm surgical specimen that was firm and scirrhous tumor located on the confluence of the right and left hepatic ducts (Klatskin tumor). Bile duct confluence had a narrow lumen but no stones or mucin. Gallbladder had no stones or wall thickening. Pathology report revealed a poorly differentiated SRC hilar cholangiocarcinoma (UICC T4N0M0) with free proximal ABCDDV/1109 and distal margins and microscopically focally positive circumferential margins (Figure 1). Resected lymph nodes had no metastases.

Wait and transplant for stage 2 hepatocellular carcinoma with deceased-donor liver grafts: how long should we wait?

Deceased-Donor Liver Grafts: How Long Should We Wait? The method which donor organs are allocated to individuals on the waiting list for transplant is an important topic for research and debate. In recent years, there has been growing interest in applying the concept of utilitarianism to the organ allocation system, seeking the maximum survival benefit of the patient population as a whole, rather than that of an individual patient (1). Ideally, exceptions points were created to allow hepatocellular carcinoma (HCC) patients a fair access to the donor pool. However, the current allocation Model for End-stage Liver Disease exception points seem to overestimate the risk disease progression and dropout in HCC patients, and the likelihood of undergoing a liver transplantation still remains higher for HCC candidates in the United States (2). Therefore, an intention-totreat analysis, such as that published in Transplantation by Chan et al. (3), is a promising tool to optimize organ donation in a more fair way. Tumor size has been associated with the risk of metastasis and HCC progression (4). Whether or not the Milan criteria could be extended without increasing waiting list mortality for non-HCC candidates depends on the availability of organs in each specific region. Thus, an optimal selection of the HCC patients for liver transplantation has an upmost importance in regions with a low donation rate. The wait-and-transplant policy proposed by Chan et al. provided almost the same chances of being transplanted for HCC and non-HCC patients, and the survival rates of those who were transplanted were almost the same in both groups (40.4% vs. 37.9%, respectively). However, most of the HCC patients in the waiting list died (n=18) or had to be excluded because of disease progression (7), and at the end of study, only 5 patients remained in conditions of being transplanted. As a matter of a fact, liver transplantation could not be offered in 48.2% (25/52) of the HCC patients. On the other hand, only 26.2% (27/103) of the non-HCC patients died in the waiting list during the same period, so 34.9% (35/103) of the non-HCC patients still had chances of receiving a liver graft when the study was ended. According to the intention-to-treat analysis, all alive and active patients should be considered as having a potential for long-term survival, regardless if they were transplanted or not. Although the outcomes of the patients who were still alive in the waiting list are unpredictable, a significant fraction of them probably will be transplanted in the following months, increasing the transplant patient rate and, consequently, the overall survival in the non-HCC group. We agree that wait-and-transplant policy is an interesting idea to avoid unnecessary liver transplant for patients at great risk of early tumor progression and recurrence, like the HCC candidates beyond the Milan criteria. The scenario of organ shortage increases even more the need to improve patient selection, but it seems to us that a shorter waiting period policy (3 months) could also combine the selection benefits of the 6-month waitand-transplant policy with a lower dropout and mortality rate on the waiting list. Another argument reinforcing this idea is the fact that HCC patients who underwent living donor liver transplantation in the same study also achieved excellent postoperative survival outcomes despite a medium waiting time to transplant of 8.5 days.