Antonio Luiz de Vasconcellos Macedo

Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35

BackgroundType 2 diabetes mellitus (T2DM) is a common disease with numerous complications. Bariatric surgery is an efficient procedure for controlling T2DM in morbidly obese patients. In T2DM, the incretin effect is either greatly impaired or absent. This study aimed to evaluate the preliminary results from interposing a segment of ileum into the proximal jejunum associated with a sleeve or diverted sleeve gastrectomy to control T2DM in patients with a body mass index (BMI) less than 35 kg/m2.MethodsFor this study, 39 patients (16 women and 23 men) underwent two laparoscopic procedures comprising different combinations of ileal interposition into the proximal jejunum via a sleeve or diverted sleeve gastrectomy. The mean age of these patients was 50.3 years (range, 36–66 years). The mean BMI was 30.1 kg/m2 (range, 23.4–34.9 kg/m2). All the patients had a diagnosis of T2DM that had persisted for at least 3 years and evidence of stable treatment with oral hypoglycemic agents or insulin for at least 12 months. The mean duration of T2DM was 9.3 years (range, 3–22 years).ResultsThe mean operative time was 185 min, and the median hospital stay was 4.3 days. Four major complications occurred in the short term (30-days), and the mortality rate was 2.6%. The mean postoperative follow-up period was 7 months (range, 4–16 months), and the mean percentage of weight loss was 22%. The mean postoperative BMI was 24.9 kg/m2 (range, 18.9–31.7 kg/m2). An adequate glycemic control was achieved for 86.9% of the patients, and 13.1% had important improvement. The patients whose glycemia was not normalized were using a single oral hypoglycemic agent. No patient needed insulin therapy postoperatively. All the patients except experienced normalization of their cholesterol levels. Targeted triglycerides levels were achieved by 71% of the patients, and hypertension was controlled for 95.8%.ConclusionsThe laparoscopic ileal interposition via either a sleeve gastrectomy or diverted sleeve gastrectomy seems to be a promising procedure for the control of T2DM and the metabolic syndrome. A longer follow-up period is needed.

Liver Metastases in Pancreatic Acinar Cell Carcinoma Treated with Selective Internal Radiation Therapy with Y-90 Resin Microspheres

Background Pancreatic acinar cell carcinoma (PACC) is a rare tumor. Surgical resection is the treatment of choice when feasible, but there are no clear recommendations for patients with advanced disease. Liver-directed therapy with Y-90 selective internal radiation therapy (SIRT) has been used to treat hepatic metastases from pancreatic tumors. We describe a case of PACC liver metastases treated with SIRT. Case Report 59-year-old man was admitted with an infiltrative, solid lesion in pancreatic tail diagnosed as PACC. Lymph nodes in the hepatic hilum were enlarged, and many metastatic liver nodules were observed. After partial pancreatectomy, the left and right lobes of the liver were separately treated with Y-90 resin microspheres. Follow-up imaging revealed that all hepatic nodules shrank by at least 50%, and 3 nodules disappeared completely. Lipase concentration was 8407 U/L at baseline, rose to 12,705 U/L after pancreatectomy, and declined to 344 U/L after SIRT. Multiple rounds of chemotherapy in the subsequent year shrank the hepatic tumors further; disease then progressed, but a third line of chemotherapy shrank the tumors again, 16 months after SIRT treatment. Conclusion SIRT had a positive effect on liver metastases from PACC. In conjunction with systemic therapy, SIRT can achieve sustained disease control.

Single-port robotic cholecystectomy. Initial and pioneer experience in Brazil

The technique of a single-port laparoscopy was developed over the last years as an attempt to lower surgical aggression and improve the aesthetic results of the minimally invasive surgery. A new robotic platform used with the da Vinci® Robotic System Single-Site System® (Intuitive Surgical, Sunnyvale, California, United States) was recently launched on the global market and is still not documented in Brazil. The authors report on the first four robotic single-port cholecystectomies performed with this da Vinci® Robotic System in Brazil.

Higher overall survival in metastatic pancreatic cancer: the impact of where and how treatment is delivered

Objective To determine the overall survival of patients with advanced pancreatic cancer and evaluate factors that impact prognosis in a private cancer center. Methods Data from the Hospital Cancer Registry at Hospital Israelita Albert Einstein were retrospectively collected. The patients enrolled had metastatic cancer at diagnosis or earlier staging and subsequent recurrence. Cases of neuroendocrine tumors were excluded. Results A total of 65 patients were evaluated, including 63 with adenocarcinoma. The median overall survival for patients in all stages was 20.7 months (95%CI: 15.6-25.7), while the overall survival of metastatic disease was 13.3 months. Among the 33 cases with stage IV cancer, there was no evidence of a statistically significant association between median survival and CA19-9 dosage (p=0.212), tumor location (p=0.482), first treatment performed (p=0.337), lymphovascular invasion (p=0.286), and age (p=0.152). However, the number of lines of chemotherapy was significantly associated with survival (log-rank p=0.013), with an estimated median survival of 10.2 months for patients who received up to two lines of treatment and 23.5 months for those receiving more than two lines of chemotherapy. Conclusion The survival of patients treated was longer than that reported in the literature. The only statistically significant factor related to increased survival was higher number of lines of chemotherapy received. We believe that the higher socioeconomic status of patients surveyed in this study, as well as their greater access to treatment options, may have influenced their overall survival.

Percutaneous treatment of complex biliary stone disease using endourological technique and literature review

Most biliary stone diseases need to be treated surgically. However, in special cases that traditional biliary tract endoscopic access is not allowed, a multidisciplinary approach using hybrid technique with urologic instrumental constitute a treatment option. We report a case of a patient with complex intrahepatic stones who previously underwent unsuccessful conventional approaches, and who symptoms resolved after treatment with hybrid technique using an endourologic technology. We conducted an extensive literature review until October 2012 of manuscripts indexed in PubMed on the treatment of complex gallstones with hybrid technique. The multidisciplinary approach with hybrid technique using endourologic instrumental represents a safe and effective treatment option for patients with complex biliary stone who cannot conduct treatment with conventional methods.

Minimally Invasive Procedures for Rare Rectal Conditions: Endometriosis

Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. Surgery remains the best long-term treatment for deep infiltrating endometriosis affecting the bowel. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery and can be succesfully employed for endometiosis- related procedures.

Secrets for successful laparoscopic antireflux surgery: robotic surgery

Surgical technique for antireflux surgery has been benefited by technology, including robotics, to achieve improved outcomes. Robotic surgery does not call for a different preoperative workup or patient selection although there are arguments that robotic surgery should be left to complex cases and reoperative surgery not to routine cases. The evaluation of current published results shows that robotic fundoplication and hiatoplasty is safe and produces outcomes similar to laparoscopic surgery. Higher operative time and costs are frequently cited as drawbacks for robotic antireflux surgery although improved experience and technology may equalize these disadvantages. At present, robotic fundoplication and hiatoplasty is comparable to laparoscopic surgery.

Robotic Near-Total Pancreatectomy for Nesidioblastosis after Bariatric Surgery.

Postprandial symptoms of neuroglycopenia after bariatric surgery may result as a consequence of endogenous hyperinsulinemic hypoglycemia (nesidioblastosis) not dumping syndrome. Pancreatectomy is an acceptable treatment for this condition. We present the video of a case of near-total distal robotic pancreactectomy for the treatment of nesidioblastosis after Roux-en-Y gastric bypass. Robotic pancreatectomy is an alternative to the treatment of nesidioblastosis after Roux-en-Y gastric bypass.

Diverticulite perfurada do apêndice cecal: diagnóstico ultrassonográfico

RESUMO A diverticulite do apendice e uma patologia incomum, eventualmente confundida com a apendicite cecal, tendo, porem, maior risco de perfuracao e de outras complicacoes. Seu diagnostico pre-cirurgico e raramente realizado, mas pode ser obtido pela ultrassonografia com a demonstracao de um diverticulo associado a sinais classicos de apendicite. Relatamos o caso de um homem adulto em que foi possivel o diagnostico ultrassonografico de diverticulite do apendice cecal e revisamos os principais aspectos relacionados a essa condicao. Diverticulite perfurada do [...]

Perforated diverticulitis of the appendix: ultrasonographic diagnosis

Appendiceal diverticulitis is an uncommon condition, mimicking appendicitis, but with greater risk of perforation and complications. Preoperative diagnosis is rare, but can be achieved by ultrasonography as identification of the diverticulum and classical signs of appendicitis. We report a case of ultrasonographic diagnosis of a perforated appendiceal diverticulitis in an adult male and discuss this condition.