Giorgio Alfredo Pedroso Baretta

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.

Laparoscopic sleeve gastrectomy with NOTES visualization--a step toward NOTES procedures.

BACKGROUND To demonstrate that bariatric procedures can be done with natural orifice visualization (NOTES) at 2 institutions (Nucleo Universitario de Estudos de Notes Centro de Cirurgia Experimental Vila do Conde-Junqueira, Vila do Conde, Portugal and Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, RS, Brasil). NOTES is a new surgical approach that is being developed. It consists of the use of a minimally invasive technique in which the surgical procedure is performed through natural orifices, thereby circumventing incisions through the skin. METHODS We performed vertical gastrectomy or laparoscopic sleeve gastrectomy in a porcine model using vaginal route visualization. RESULTS A laparoscopic vertical sleeve gastrectomy with NOTES visualization in a porcine model was performed with safety. CONCLUSION Bariatric procedures can be done with NOTES with results as good as those using laparoscopic techniques.

Post-bariatric surgery weight regain: evaluation of nutritional profile of candidate patients for endoscopic argon plasma coagulation

Background Bariatric surgery is effective treatment for weight loss, but demand continuous nutritional care and physical activity. They regain weight happens with inadequate diets, physical inactivity and high alcohol consumption. Aim To investigate in patients undergoing Roux-Y-of gastroplasty weight regain, nutritional deficiencies, candidates for the treatment with endoscopic argon plasma, the diameter of the gastrojejunostomy and the size of the gastric pouch at the time of treatment with plasma. Methods A prospective 59 patients non-randomized study with no control group undergoing gastroplasty with recurrence of weight and candidates for the endoscopic procedure of argon plasma was realized. The surgical evaluation consisted of investigation of complications in the digestive system and verification of the increased diameter of the gastrojejunostomy. Nutritional evaluation was based on body mass index at the time of operation, in the minimum BMI achieved after and in which BMI was when making the procedure with plasma. The laboratory tests included hemoglobin, erythrocyte volume, ferritin, vitamin D, B12, iron, calcium, zinc and serum albumin. Clinical analysis was based on scheduled follow-up. Results Of the 59 selected, five were men and 51 women; were included 49 people (four men and 44 women) with all the complete data. The exclusion was due to the lack of some of the laboratory tests. Of this total 19 patients (38.7%) had a restrictive ring, while 30 (61.2%) did not. Iron deficiency anemia was common; 30 patients (61.2%) were below 30 with ferritin (unit); 35 (71.4%) with vitamin B12 were below 300 pg/ml; vitamin D3 deficiency occurred in more than 90%; there were no cases of deficiency of protein, calcium and zinc; glucose levels were above 99 mg/dl in three patients (6.12%). Clinically all had complaints of labile memory, irritability and poor concentration. All reported that they stopped treatment with the multidisciplinary team in the first year after the operation. Conclusions The profile of patients submitted to argon plasma procedure was: anastomosis in average with 27 mm; multiple nutritional deficiencies with predominance of iron deficiency anemia; ferritin below 30; vitamin B12 levels below 300 pg/ml; labile memory complaints, irritability and poor concentration.

Estudo comparativo de eficácia e segurança entre propofol e midazolam durante sedação para colonoscopia

OBJETIVO: Comparar a seguranca e a eficacia do propofol com a do midazolam na sedacao profunda durante colonoscopias. METODOS: Sessenta e seis pacientes foram submetidos a colonoscopias e estudados prospectivamente. Um total de 50 pacientes recebeu 3,25 mg.kg-1 de peso de propofol. No grupo controle de 16 pacientes foi administrado 2,05 mg.kg-1 de peso de midazolam. A dose de manutencao foi titulada de acordo com a necessidade. Os parâmetros cardiovasculares e respiratorios observados foram a saturacao de oxigenio, pressao arterial sistolica e diastolica e frequencia cardiaca. Apos o procedimento foi realizado um questionario sobre intercorrencias como dor, desconforto e satisfacao apos a colonoscopia, utilizando uma escala visual de zero a dez. Foi aplicado o teste t de Student para a analise estatistica. RESULTADOS: A amostra foi similar com relacao as variaveis idade, peso, sexo e condicao fisica. Houve diferenca estatistica significativa para os parâmetros saturacao de oxigenio do sangue e pressao arterial sistolica entre os dois grupos. Nao houve diferenca estatistica significativa para os parâmetros pressao arterial diastolica e pulso. Apesar das diferencas nos parâmetros cardiovasculares e respiratorios, nao houve repercussoes hemodinâmicas significativas. Nao houve diferenca estatistica no parâmetro dor e satisfacao. Os pacientes que apresentaram agitacao (25%) no grupo midazolam, relataram mais desconforto (p=0,038). CONCLUSAO: As variacoes nos parâmetros cardiovasculares e respiratorios, mesmo com diferencas significativas entre os grupos, nao causaram repercussoes clinicas significativas nos dois grupos, caracterizando a seguranca na sedacao profunda. A sedacao com midazolam ou propofol nao esta associada a niveis de dor e satisfacao diferentes entre os dois grupos. O grupo midazolan referiu significativamente mais desconforto que o grupo propofol.

Fatores prognósticos relacionados à falha do tratamento não-operatório de lesões esplênicas no trauma abdominal fechado

OBJECTIVE: Identify prognostic factors related to treatment failure of blunt splenic injuries managed by non surgical treatment (NST). METHODS: Fifty six adult patients submitted to NST were prospectively studied. The injuries were diagnosed by computed axial tomography scan and classified according to AAST (American Association for Surgery of Trauma) criteria. Patients were divided in success and failure groups. NST failure was defined as the need for laparotomy for any reason. RESULTS: NST failures (19.6%) were due to: abdominal pain (45.4%), hemodinamic instability (36.4%), splenic haematoma associated to a fall in hematocrit (9.1%) and splenic abscess (9.1%). There were no failures in grade I and II of the splenic injuries; failure rate was 17.5% in grade III and IV injuries grouped, and 80% in grade V injuries (p = 0,0008). In the success group, 31.3% patients received red cell transfusions, versus 63.6% patients in the failure group (p = 0,05). Failure rate in patients with ISS = 8 was zero; 15.9% in patients with ISS 9 to 25; and 50% in patients with ISS = 26 (p = 0,05). There were no deaths or missed bowel injuries. CONCLUSION: ISS and splenic injury grade were related to failure of NST.

Anemia pós-cirurgia bariátrica: as causas nem sempre são relacionadas à cirurgia

RACIONAL: As anemias ferropriva, perniciosa e megaloblastica sao comuns apos procedimentos bariatricos como o bypass e as derivacoes biliopancreaticas. As principais causas devem-se ao desvio duodenal e do jejuno proximal do trânsito alimentar e, em menor grau, as ulceras anastomoticas. Entretanto a dieta pobre em nutrientes, a suplementacao vitaminica inadequada, medicamentos, uso de alcool e neoplasias devem ser lembrados. RELATO DOS CASOS: Os autores relatam dois casos de pacientes pos-procedimentos bariatricos com anemia severa sem controle clinico e cuja investigacao identificou melanoma metastatico em um caso e neoplasia colonica no segundo, ambos tratados cirurgicamente com bons resultados. CONCLUSAO: Anemias sao comuns apos procedimentos bariatricos, porem causas atipicas como neoplasias devem ser suspeitadas nos pacientes mais idosos e principalmente naqueles refratarios ao controle clinico.

Sirolimus influence on hepatectomy-induced liver regeneration in rats

OBJECTIVE To evaluate the influence of sirolimus on liver regeneration triggered by resection of 70% of the liver of adult rats. METHODS we used 40 Wistar rats randomly divided into two groups (study and control), each group was divided into two equal subgroups according to the day of death (24 hours and seven days). Sirolimus was administered at a dose of 1mg/kg in the study group and the control group was given 1 ml of saline. The solutions were administered daily since three days before hepatectomy till the rats death to removal of the regenerated liver, conducted in 24 hours or 7 days after hepatectomy. Liver regeneration was measured by the KWON formula, by the number of mitotic figures (hematoxylin-eosin staining) and by the immunohistochemical markers PCNA and Ki-67. RESULTS there was a statistically significant difference between the 24h and the 7d groups. When comparing the study and control groups in the same period, there was a statistically significant variation only for Ki-67, in which there were increased numbers of hepatocytes in cell multiplication in the 7d study group compared with the 7d control group (p = 0.04). CONCLUSION there was no negative influence of sirolimus in liver regeneration and there was a positive partial effect at immunohistochemistry with Ki-67.

Endoscopic plasma argon coagulation in treatment of weight regain after bariatric surgery: what does the patient think about this?

Background Bariatric surgery, especially Roux-en-Y gastric bypass is an effective treatment for refractory morbid obesity, causing the loss of 75% of initial excess weight. After the surgery, however, weight regain can occur in 10-20% of cases. To help, endoscopic argon plasma coagulation (APC) is used to reduce the anastomotic diameter. Many patients who undergo this treatment, are not always familiar with this procedure and its respective precautions. Aim The aim of this study was to determine how well the candidate for APC understands the procedure and absorbs the information provided by the multidisciplinary team. Method We prepared a questionnaire with 12 true/false questions to evaluate the knowledge of the patients about the procedure they were to undergo. The questionnaire was administered by the surgeon during consultation in the preoperative period. The patients were invited to fill out the questionnaire. Results We found out that the majority learned about the procedure through the internet. They knew it was an outpatient treatment, where the anesthesia was similar to that for endoscopy, and that they would have to follow a liquid diet. But none of them knew that the purpose of this diet was to improve local wound healing. Conclusion Bariatric patients who have a second chance to resume weight loss, need continuous guidance. The internet should be used by the multidisciplinary team to promote awareness that APC will not be sufficient for weight loss and weight-loss maintenance in the long term. Furthermore, there is a need to clarify again the harm of drinking alcohol in the process of weight loss, making its curse widely known.

Imunossupressão com tacrolimus favorece a regeneração hepática induzida por hepatectomia ampla em ratos

OBJETIVO: Avaliar em dois momentos distintos da regeneracao hepatica a influencia do Tacrolimus sobre o fenomeno da regeneracao hepatica desencadeada pela resseccao de 70% do parenquima hepatico em ratos plenamente desenvolvidos. METODOS: Utilizaram-se 40 ratos Wistar com peso medio de 510,08 g ± 11.66 g distribuidos aleatoriamente em dois grupos de 20, cada grupo subdividido em dois subgrupos conforme o dia da morte apos a hepatectomia. De acordo com o grupo os animais receberam por gavagem solucao aquosa de Tacrolimus 0,1 mg/kg/dia ou solucao salina no mesmo volume. Apos tres dias de pre-terapia todos foram submetidos a hepatectomia de 70% pela resseccao dos lobos hepaticos mediano e lateral esquerdo que foram pesados para posterior calculo da regeneracao hepatica pela formula de Kwon. Vinte e quatro horas ou sete dias apos a hepatectomia, 10 animais de cada grupo foram mortos, os figados remanescentes (regenerados) foram pesados e amostrados para realizacao de indice mitotico por hematoxilina-eosina e estudo imunoistoquimico com os marcadores PCNA e Ki-67. RESULTADOS: Os animais que receberam tacrolimus mostraram indice maior de regeneracao hepatica, atingindo significância estatistica quando comparado ao subgrupo de animais mantidos com placebo quando analisados pelos parâmetros: formula de Kwon, indice mitotico e marcador PCNA. A tendencia para o marcador Ki-67 foi identica aos outros parâmetros mas nao alcancou significância estatistica. CONCLUSAO: A imunossupressao com tacrolimus possui efeito estimulatorio no processo de regeneracao hepatica desencadeado pela hepatectomia 70% em ratos Wistar adultos, plenamente desenvolvidos.

Seleção e uso de antibióticos em infecções intra-abdominais

BACKGROUND: Intra-abdominal infections are common and are associated with elevated morbidity and mortality. The microorganisms that cause intra-abdominal infections are usually from the gastrointestinal flora, mainly E. coli and Bacteroides fragilis. AIM: To present a review of the selection and use of antibiotics in intra-abdominal infections. CONCLUSIONS: Appropriate use of antibiotics is essential to control infection and to reduce treatment failure. Antibiotics are initiated whenever intra-abdominal infection is suspected and the antimicrobial agents are selected based on the most common microorganisms involved. In addition, efficacy, cost, safety, and posologic regimen are considered for an appropriated selection. Antibiotic regimen is different whether the infection is acquired in the community or at hospital due to the more resistant flora in the latter.