Carolina Gomes Gonçalves

Late laparoscopic reoperation of failed antireflux procedures.

Failures of antireflux procedures occur in 5% to 10% of the patients. Our objective is to report our experience with laparoscopic management of failed antireflux operations. Of 1698 patients who underwent laparoscopic treatment of gastroesophageal reflux disease (GERD), 53 were reoperations following either a previous open or laparoscopic antireflux procedure. The indications for surgical reoperation were persistent or recurrent GERD in 35 patients (66%), presence of paraesophageal hiatal hernia in 4 (7.5%), and severe dysphagia in 14 (26.4%). Hospital stay varied from 1 to 8 days, with an average of 1.2 days. Conversion to open laparotomy occurred in 10 patients (18.8%). The main causes for persistent or recurrent GERD were herniation (n=20) and disruption (n=12) of the fundoplication. Two patients had both herniation and disruption of the fundoplication. The main reason for severe dysphagia was tight hiatus. The most common reoperations were hiatal repair for hernia correction (n=26), redo fundoplication (n=16), and widening of the hiatus (n=12). Two patients had both hiatal repair and redo fundoplication. Intra (n=5) and postoperative (n=16) complications were frequent, but they were usually minor. There was no mortality. The present study demonstrated that laparoscopic reoperation for failed antireflux procedures may be performed safely in most patients with excellent result, low severe morbidity, and no mortality.

Liver resection: 10-year experience from a single Institution

BACKGROUND Liver resection constitutes the main treatment of most liver primary neoplasms and selected cases of metastatic tumors. However, this procedure is associated with significant morbidity and mortality rates. AIM To analyze our experience with liver resections over a period of 10 years to determine the morbidity, mortality and risk factors of hepatectomy. PATIENTS AND METHODS Retrospective review of medical records of patients who underwent liver resection from January 1994 to March 2003. RESULTS Eighty-three (41 women and 42 men) patients underwent liver resection during the study period, with a mean age of 52.7 years (range 13-82 years). Metastatic colorectal carcinoma and hepatocellular carcinoma were the main indications for hepatic resection, with 36 and 19 patients, respectively. Extended and major resections were performed in 20.4% and 40.9% of the patients, respectively. Blood transfusion was needed in 38.5% of the operations. Overall morbidity was 44.5%. Life-threatening complications occurred in 22.8% of cases and the most common were pneumonia, hepatic failure, intraabdominal collection and intraabdominal bleeding. Among minor complications (30%), the most common were biliary leakage and pleural effusion. Size of the tumor and blood transfusion were associated with major complications (P = 0.0185 and P = 0.0141, respectively). Operative mortality was 8.4% and risk factors related to mortality were increased age and use of vascular exclusion (P = 0.0395 and P = 0.0404, respectively). Median hospital stay was 6.7 days. CONCLUSION Liver resections can be performed with low mortality and acceptable morbidity rates. Blood transfusion may be reduced by employing meticulous technique and, whenever indicated, vascular exclusion.

Influence of Preoperative Feeding on the Healing of Colonic Anastomoses in Malnourished Rats

BACKGROUND Malnutrition influences healing of gastrointestinal anastomoses. The authors hypothesize that colonic anastomotic healing is decreased by malnutrition and might be improved by preoperative feeding. METHODS Eighty adult male Wistar rats were divided into 4 groups: (1) control rats 1 (C1), fed regular chow ad libitum for 21 days; (2) malnourished pair-fed rats (M), fed 50% of the food ingested by the control rats for 21 days; (3) preoperative nutrition rats (PRE), fed 50% of the average of the controls for 21 days and then fed preoperative nutrition with regular chow ad libitum for 1 week before the operation; and (4) control rats 2 (C2), fed regular chow ad libitum for 28 days. On days 21 (C1 and M) and 28 (PRE and C2), rats underwent 2 colonic transections and, subsequently, 2 end-to-end anastomoses. Rats were killed on postoperative day 5. The anastomoses were resected for tensile strength and histological analysis. RESULTS PRE rats showed increased maximal tensile strength vs the M group (0.09+/-0.01 vs 0.15+/-0.01; P<.05) and similar values of maximal tensile strength as the controls (0.15+/-0.01 vs 0.15+/-0.02; P=.91). Collagen type I was higher in controls vs the PRE group (6.13+/-0.39 vs 4.90+/-1.53; P<.05); nevertheless, the PRE group showed higher collagen type I than M rats (4.90+/-0.36 vs 3.83+/-0.35; P<.05). CONCLUSIONS Preoperative feeding for 7 days increases the maximal tensile strength, as well as the percentage area of mature collagen, approaching similar values as the control group.

Evaluation of the nonalcoholic fat liver disease fibrosis score for patients undergoing bariatric surgery.

CONTEXT Morbidly obese patients have an increased risk for nonalcoholic fat liver disease. Its severe form, nonalcoholic steatohepatitis may cause liver fibrosis. The diagnosis of advanced fibrosis has great value during the pre operative evaluation for bariatric surgery. Currently, liver biopsy is the gold standard for diagnosis of liver fibrosis. OBJECTIVE To evaluate the nonalcoholic fat liver disease fibrosis score in morbidly obese patients undergoing Roux-en-Y gastric bypass in our population. METHODS One hundred fifty-eight morbidly obese patients that had undergone bariatric surgery were included. Age, body mass index, hyperglycemia, platelet count, albumin and AST/ALT ratio were applied to the score formula. Scores above 0.676 were indicative of advanced liver fibrosis and scores under -1,455 absence of advanced liver fibrosis. These scores were compared to liver biopsy findings. RESULTS The presence of advanced fibrosis could be diagnosed with good accuracy, with a positive predictive value of 83.7%. The score had a higher accuracy to exclude advanced fibrosis with a negative predictive value of 97%. Twenty-five patients (16%) had scores between the cutoffs points and were identified as indeterminate. The score sensibility and specificity was 83% and 97% respectively. CONCLUSIONS The nonalcoholic fat liver disease fibrosis score has high accuracy to identify and exclude advanced liver fibrosis in morbidly obese patients subjected to bariatric surgery.

Fatores de risco e conduta nas complicações do trato biliar no transplante hepático

A reconstrucao biliar e um dos pontos vulneraveis do transplante hepatico apresentando incidencia de complicacoes biliares, variando de 10 a 35%, nos diversos estudos da literatura. Esse trabalho tem por objetivo apresentar a experiencia do nosso servico em relacao a incidencia e ao manejo das complicacoes biliares no transplante de figado. Foram incluidos no estudo 147 transplantes hepaticos ortotopicos, com idade media de 37,3 anos, correspondendo a 88 procedimentos em pacientes do sexo masculino e 59 do sexo feminino. Complicacoes biliares ocorreram em 27 transplantes (18,36%) em 25 pacientes (dois retransplantes). A presenca de rejeicao celular e de complicacoes vasculares foi identificada como fator de risco para as complicacoes biliares. A idade, o sexo, a etiologia da cirrose e a tecnica utilizada na reconstrucao biliar nao foram fatores de risco. No total, foram empregados 52 cursos terapeuticos: tratamento cirurgico em 23 vezes; tratamento endoscopico em 15 vezes; retransplante em sete vezes; drenagem biliar transparieto-hepatica em seis vezes e um paciente esta em lista de espera para retransplante. Conclui-se deste estudo que as complicacoes biliares sao frequentes apos o transplante hepatico e que as vasculares e a rejeicao celular sao fatores de risco.

Complicações vasculares pós-transplante hepático

OBJETIVO: O objetivo do estudo e apresentar as complicacoes vasculares arteriais e venosas observadas em um servico de transplante hepatico universitario brasileiro. METODOS: Os prontuarios de todos os pacientes submetidos a transplante hepatico no periodo de setembro de 1991 a janeiro de 2000 foram analisados para determinar as complicacoes vasculares e correlaciona-las a dados clinicos e do procedimento cirurgico. RESULTADOS: Foram realizados 169 transplantes, sendo quatro inter vivos e nove retransplantes. Um total de 24 complicacoes vasculares (14,3%) foi identificado em 22 pacientes (13,0%). A complicacao vascular mais comum foi a trombose da arteria hepatica (15 casos), seguido da trombose da veia porta (quatro casos). Complicacoes da veia cava inferior infra ou supra-hepatica foram incomuns, ocorrendo em um total de tres casos (1,8%). As complicacoes vasculares foram mais frequentes nas criancas (26,06%) do que em adultos (13,14%) (p<0,05). Dos pacientes com trombose da arteria hepatica, um foi submetido a angioplastia, um a trombectomia, oito a retransplante e cinco evoluiram para o obito enquanto aguardavam retransplante. Dos quatro casos de trombose da veia porta, dois foram a obito, um foi submetido a colocacao percutânea de protese e um a tratamento conservador. Os pacientes com estenose da veia porta e da veia cava inferior infra e supra-hepatica foram submetidos a tratamento conservador, com boa evolucao clinica. CONCLUSOES: que as complicacoes vasculares sao frequentes apos o transplante hepatico, principalmente em criancas, e sao associadas a elevada morbidade, mortalidade e retransplante.

Obstrução intestinal após uso de infliximab no tratamento de fístula êntero-cutânea na doença de Crohn

Crohns disease is often complicated by the development of fistulas. Infliximab, a monoclonal antibody that binds tumor necrosis factor a have shown to be successful in the treatment of fistulizing Crohns disease. Its possible complications and side effects have not been completely elucidated. Our objective is to report a case of a patient who developed intestinal obstruction after treatment of fistulizing Crohns disease with infliximab. A 50 years-old female with Crohns disease presented with spontaneous enterocutaneous fistula. She was successfully treated with the infusion of 5mg/kg infliximab at weeks 0, 2, and 6, with complete closure of the fistula after the first infusion. Eight weeks after treatment she developed small bowel obstruction secondary to stenosis of the ileum. She was subjected to exploratory laparotomy and resection of the stenotic ileum. The patient had good recovery, with no complications, and was discharged on the 5th postoperative day. Although a faster and complete healing of enterocutaneous fistula was induced by infliximab, this treatment may have caused intestinal obstruction in this case.

Laparoscopic treatment of peri-appendicitis caused by intrauterine contraceptive device

BACKGROUND Intrauterine device may perforate the uterus and cause several complications. AIM To report a case of laparoscopic treatment of peri-appendicitis caused by intrauterine device. PATIENT AND METHOD A young female presented with pain in the right lower abdomen of 4 days of duration. On the physical examination, she had localized abdominal pain in the right lower abdomen with discrete guarding and pain on percussion and rebound tenderness. Ultrasonography showed an intrauterine device outside of the uterus, in the right lower of the abdomen. RESULTS At laparoscopy, an inflammatory mass that consisted of the intrauterine device blocked by the mesoappendix and the appendix was observed. Appendectomy and removal of the intrauterine device were performed. CONCLUSION Laparoscopy allows adequate treatment of peri-appendicitis caused by intrauterine device, inclusive with complete evaluation of the entire pelvic region to rule out associated complications

Anatomia cirúrgica do acesso nasal transesfenoidal para tumores da hipófise

Foram analisadas diferentes medidas relacionadas ao acesso nasal transesfenoidal em 18 hemicabecas de cadaveres com o objetivo de estudar os limites e vantagens dessa via. Foram obtidos os seguintes valores medios (mm) para as principais medidas: diâmetro maior da narina 15,18; altura da cavidade nasal 44,11; distância narina - sela turca 71,71. Esses valores demonstram ser o acesso nasal uma via ampla e direta a sela turca. O presente estudo demonstrou tambem ser possivel nesse acesso preservar o septo cartilagino e outras estruturas que sao usualmente lesadas no acesso sublabial.