Fabricio Ferreira Coelho

Study of the proximal femoral fractures mortatlity in elderly patients

Foi feito um estudo de revisao sobre a mortalidade na fratura do femur proximal em idosos com base nas publicacoes mais relevantes do periodo de 1998 a 2002. Foram incluidos 25 artigos relacionados ao assunto, selecionados com base nos bancos de dados Medline e Cochrane, totalizando 24.062 pacientes com mais de 60 anos de idade, que tiveram fratura do femur proximal. Quatorze estudos foram prospectivos, oito retrospectivos e tres revisoes sistematicas. As taxas medias de mortalidade foram de 5,5% durante a internacao hospitalar, 4,7% ao fim de um mes de seguimento, 11,9% com tres meses, 10,8% com seis meses, 19,2% com um ano e 24,9% com dois anos. Foram identificados quatro fatores intimamente relacionados com uma maior mortalidade nestes pacientes: idade avancada, grande numero de doencas associadas, sexo masculino e presenca de deficiencias cognitivas. Outros fatores mostraram uma fraca correlacao com a mortalidade como capacidade deambulatoria previa, indice de risco anestesico da Sociedade Americana de Anestesia (ASA), anemia, hipoalbuminemia, linfopenia e existencia de AVC previo. Os fatores como tempo previo a cirurgia, tipo de anestesia utilizada e tipo de osteossintese empregada nao mostraram ter interferencia.

Hepatocellular adenoma: an excellent indication for laparoscopic liver resection.

OBJECTIVES Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA. METHODS Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm. RESULTS The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days. CONCLUSIONS Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.

Tumor growth pattern as predictor of colorectal liver metastasis recurrence

BACKGROUND Surgical resection is the gold standard therapy for the treatment of colorectal liver metastases (CRM). The aim of this study was to investigate the impact of tumor growth patterns on disease recurrence. METHODS We enrolled 91 patients who underwent CRM resection. Pathological specimens were prospectively evaluated, with particular attention given to tumor growth patterns (infiltrative vs pushing). RESULTS Tumor recurrence was observed in 65 patients (71.4%). According to multivariate analysis, 3 or more lesions (P = .05) and the infiltrative tumor margin type (P = .05) were unique independent risk factors for recurrence. Patients with infiltrative margins had a 5-year disease-free survival rate significantly inferior to patients with pushing margins (20.2% vs 40.5%, P = .05). CONCLUSIONS CRM patients with pushing margins presented superior disease-free survival rates compared with patients with infiltrative margins. Thus, the adoption of the margin pattern can represent a tool for improved selection of patients for adjuvant treatment.

Initial experience with stapled hemorrhoidopexy for treatment of hemorrhoids

BACKGROUND Introduction of stapled hemorrhoidopexy by Longo in 1998 represented a radical change in the treatment of hemorrhoids. By avoiding multiple excisions and suture lines in the perianal region, stapled hemorrhoidopexy is intended to offer less postoperative pain than with conventional techniques. OBJECTIVE To report and analyze the intra and postoperative results gained during initial experience with stapled hemorrhoidopexy. METHODS One hundred and fifty five patients (67 males) with average age of 39.5 years (21-67 years) underwent stapled hemorrhoidopexy between June 2000 and December 2003 with symptomatic third-degree (n = 74) and fourth-degree (n = 81) hemorrhoids. Mean follow-up period was 20 months (14-60 months). RESULTS Preoperative symptoms were prolapse (96.7%) and anal bleeding (96.1%). Overall mean operative time was 23 minutes (16-48 minutes). We observed one case of stapler failure and one case of failure to introduce the stapler occurred in a patient with previous anal surgery. Additional sutures for hemostasis were required in 103 patients (66.5%). Resection of skin tags was performed in 45 cases (29%). Postoperatively scheduled analgesia with oral dipyrone and celecoxib was enough for pain control in 131 patients (84.5%). Rescue analgesia was necessary in 24 cases (15.5%). Five patients needed opiates for pain control. Hospital discharge took place on the first postoperative day in 140 patients (90.3%). First defecation without pain was reported by 118 patients (76.1%). Postoperative complications were anal bleeding (10.3%), severe pain (3.2%), urinary retention (3.9%), fever without any signs of perianal infection (1.9%), incontinence for flatus (1.9%), hemorrhoidal thrombosis (1.3%). Two patients presented symptoms of recurrent hemorrhoidal disease and were successfully treated by conventional hemorrhoidectomy. They were no cases of anal stenosis, permanent incontinence, chronic pain or deaths in this series. CONCLUSIONS Hemorrhoidopexy can be considered a feasible and safe alternative technique to conventional hemorroidectomy for select patients.

Lymphadenectomy in Colorectal Cancer Liver Metastases Resection: Incidence of Hilar Limph Nodes Micrometastasis

Liver resection is considered the best treatment for metastatic colorectal cancer. Several prognostic factors have been investigated, and many studies have shown that hepatic hilum lymph nodes involvement has a negative impact on prognosis. The present study evaluated the frequency of microscopic involvement of hilar lymph nodes, through systematic lymphadenectomy and analysis of micrometastases in patients undergoing hepatectomy due to colorectal metastasis.

Half-Pringle Maneuver: A Useful Tool in Laparoscopic Liver Resection

INTRODUCTION Laparoscopic liver resections are becoming a common procedure, and bleeding remains the major concern during parenchymal transection. Total vascular inflow occlusion can be performed, but ischemic reperfusion injuries can lead to postoperative morbidity. On the other hand, hemihepatic inflow occlusion, leading to hemiliver ischemia, decreases the amount of liver parenchyma submitted to reperfusion damage and offers the advantage of reduced blood loss. OBJECTIVE The aim of this work was to describe our experience with laparoscopic the half-Pringle maneuver for segmentar or nonanatomic liver resctions. PATIENTS AND METHODS Eight patients submitted to laparoscopic liver resection in a single tertiary center. RESULTS There were 5 women and 3 men with a mean age of 40.2 years (range, 26-54). Mean tumor size was 4.1 cm (range, 2.6-6.0), and mean hospital stay was 3.1 days (1-5). There were 3 liver adenomas, 2 hepatocellular carcinomas, 1 metastatic melanoma, 1 metastatic colorectal carcinoma, and 1 peripheral colangiocarcinoma. No postoperative complications or mortalities were observed. CONCLUSIONS Results demonstrate that laparoscopic liver resection with the half-Pringle maneuver is feasible and safe and may be included in the technical armamentarium of laparoscopic liver resections for a selected group of patients.

High Mortality Rates After ALPPS: the Devil Is the Indication

Surgical resection with R0 margins still remains the ultimate goal for most liver malignancies [1]. In many cases, a complete margin-free resection represents a challenge especially when lesions might present as giant masses (i.e., hepatocellular carcinoma, intrahepatic cholangiocarcinoma), compromising major vessels, or as bilobar multicentric disease (i.e., metastatic colorectal carcinoma), demanding extended resections. In order to obtain complete resection of tumors that are large, multiple, or oddly located, a great amount of parenchyma is sacrificed, with the greatest concern being the future liver remnant (FLR) and posthepatectomy liver failure [2]. Santibañes and Clavien [3] wrote an elegant editorial enumerating important surgical advances that provided the possibility of curative resection for patients with an extensive tumor load in the liver, such as portal vein embolization, staged liver resection, and the association of both procedures. There is no doubt that these techniques provided a significant advance enabling the treatment of patients with large tumor masses, avoiding a small liver remnant and consequently preventing postoperative liver failure. Recently, an innovative operation combining the principles of these aforementioned strategies has become an alternative approach to increase the FLR in major hepatectomies [3]. The associating liver partition and portal vein ligation for staged hepatectomy—termed as ALPPS—has triggered many and heated debates along recent years. The new concept of in situ liver partition associated to portal vein ligation leading to a fast and significant contralateral parenchyma hypertrophy was first performed by Hans Schlitt in 2007, being the first scientific report by Baumgart et al. in 2011 and popularized by Santibañes and his colleagues [4]. Schnitzbauer et al. [5] in a cooperative experience from 5 German centers with 25 patients showed aspects that should be addressed. In this initial experience, a high morbidity rate (68 %) and a concerning mortality rate (12 %) were reported; on the other hand, an impressive volume growth in a short period of time and low rates of postoperative liver failure were observed. ALPPS is still under evaluation in a stage between exploration and assessment [6]. Indeed, the experience with ALPPS is lacking and we still seek the best indications to perform it. Moreover, regarding the surgical technique itself, the procedure is not well standardized. P. Herman : J. A. P. Krüger (*) :M. V. Perini : F. F. Coelho Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Rua Dr. Enéas de Carvalho Aguiar, 255 9° andar sala 9025, São Paulo, SP CEP 05403-900, Brazil e-mail: jaime.kruger@hc.fm.usp.br

Downstaging and resection after neoadjuvant therapy for fibrolamellar hepatocellular carcinoma.

Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare malignant liver neoplasm, commonly observed in adolescents and young adults of both genders. The disease is more common in Caucasians and in patients without a prior history of liver disease. The best treatment option is a surgical resection associated with liver hilum lymph node dissection. However, there is no established systemic drug treatment for patients with locally advanced or metastatic disease. We report on a patient with advanced FLHCC, initially considered unresectable due to invasion of the right and the middle hepatic veins and circumferential involvement of the left hepatic vein. Following the treatment with gemcitabine-oxaliplatin systemic chemotherapy, the patient exhibited a significant tumor reduction. As a result, a complete resection was performed with an extended right hepatectomy associated with a partial resection of the inferior vena cava, a wedge resection in segment 2, and lymphadenectomy of the hepatic hilum. The case was unusual due to the significant tumor downstaging with gemcitabine-oxaliplatin, potentially enabling curative resection. More studies are needed to confirm the efficacy of the systemic drug treatment for FLHCC.

Prognostic implication of mucinous histology in resected colorectal cancer liver metastases.

BACKGROUND Colorectal mucinous adenocarcinoma (MAC) is a subtype of colorectal adenocarcinoma with prominent mucin production associated with proximal location of tumor, advanced stage at diagnosis, microsatellite instability, and BRAF mutation. The prognostic implication of MAC in colorectal cancer liver metastases (CRCLM) is unknown. The purpose of our study was to determine the frequency and elucidate the prognostic implication of mucinous histology in CRCLM. METHODS The medical records of 118 patients who underwent CRCLM resection between 2000 and 2010 were reviewed. Clinicopathologic variables and outcome parameters were examined. Resected specimens were submitted to routine histologic evaluation. Patients were grouped according to the metastasis mucinous content: >50%, MAC; <50%, adenocarcinoma with intermediated mucinous component (AIM); and without any mucinous component, non-MAC (NMA). RESULTS Mean follow-up after resection was 37 months. Tumor recurrence was observed in 75% of patients. Overall survival and disease-free survival rates after hepatectomy were 61%, 56%, and 26%, 24% at 3 and 5 years, respectively. Tumors with mucinous component (AIM and MAC) were related to proximal location of the primary tumor and were more frequently observed in females. Multivariate analysis revealed that MAC was an independent negative prognostic factor (hazard ratio, 3.13; 95% CI, 1.30-6.68; P = .011) compared with non-MAC (NMA and AIM). CONCLUSION MAC has an adverse prognostic impact compared with NMA, which may influence therapeutic strategy raising an important subject for discussion and future investigation.

Dimensão da margem cirúrgica nas ressecções de metástase hepática de câncer colorretal: impacto na recidiva e sobrevida

BACKGROUND Approximately 50% of the patients with a colorectal tumor develop liver metastasis, for which hepatectomy is the standard care. Several prognostic factors have been discussed, among which is the surgical margin. This is a recurring issue, since no consensus exists as to the minimum required distance between the metastatic nodule and the liver transection line. AIM To evaluate the surgical margins in liver resections for colorectal metastases and their correlation with local recurrence and survival. METHODS A retrospective study based on the review of the medical records of 91 patients who underwent resection of liver metastases of colorectal cancer. A histopathological review was performed of all the cases; the smallest surgical margin was verified, and the late outcome of recurrence and survival was evaluated. RESULTS No statistical difference was found in recurrence rates and overall survival between the patients with negative or positive margins (R0 versus R1); likewise, there was no statistical difference between subcentimeter margins and those greater than 1 cm. The disease-free survival of the patients with microscopically positive margins was significantly worse than that of the patients with negative margins. The uni- and multivariate analyses did not establish the surgical margin (R1, narrow or less than 1 cm) as a risk factor for recurrence. CONCLUSION The resections of liver metastases with negative margins, independently of the margin width, had no impact on tumor recurrence (intra- or extrahepatic) or patient survival.