Gustavo Justo Schulz

The role of nutrition in hepatic encephalopathy.

Purpose of reviewProtein-calorie malnutrition may be observed in all clinical stages of liver disease. Nutritional management in these patients is imperative. It is crucial that protein intake is not restricted ad hoc. Administration of vegetable proteins for patients who cannot tolerate standard proteins and, if necessary, branched-chain amino acid-enriched formulae can be an option to these patients. This issue, however, remains controversial. Recent findingsThis study is an update on the nutritional management of hepatic encephalopathy based on several studies of the last decades, involving dietary protein intake and branched-chain amino acid supplementation. SummaryMalnutrition is a common complication of liver disease and it adversely affects patient outcome. Inadequate dietary protein intake has a very deleterious effect on hepatic encephalopathy, nutritional status, and clinical outcome in these patients and must be avoided. The administration of branched-chain amino acids stimulates hepatic protein synthesis, reduces postinjury catabolism and therefore improves nutritional status. Conflicting results in various different trials, however, exist, and this issue remains unclear.

Prevalence of hepatopulmonary syndrome in liver transplant candidates

Background - Hepatopulmonary syndrome is an important clinical problem associated with chronic liver disease. Liver transplantation can result in complete resolution of the arterial hypoxemia associated with this syndrome, even in its most severe presentation. Aim - To determine the prevalence of hepatopulmonary syndrome in adult liver transplant candidates. Patients and Methods - Fifty-four consecutives adult patients (³18 years) with severe liver disease waiting for liver transplant were screenned for arterial hypoxemia (PaO2 <70 mm Hg) while they were seated, at rest, and breathing room air. Patients with arterial hypoxemia underwent contrast-enhanced two-dimensional echocardiography and pulmonary function testing. Hypoxemia (PaO2 <70 mm Hg) was present in 7 of 54 patients (12,9%), although only 1 of them complained of dyspnea. The Childs classification of the patients were: A = 1, B = 4, and C = 1. All seven hypoxemic patients had positive contrast-enhanced two-dimensional echocardiography, consistent with hepatopulmonary syndrome. Conclusion - The prevalence of hepatopulmonary syndrome in adult liver transplant candidates is elevated. The screenning for hepatopulmonay syndrome should be part of the routine evaluation of liver transplant candidates even in the absence of pulmonary symptoms.BACKGROUND Hepatopulmonary syndrome is an important clinical problem associated with chronic liver disease. Liver transplantation can result in complete resolution of the arterial hypoxemia associated with this syndrome, even in its most severe presentation. AIM To determine the prevalence of hepatopulmonary syndrome in adult liver transplant candidates. PATIENTS AND METHODS Fifty-four consecutives adult patients (> or = 18 years) with severe liver disease waiting for liver transplant were screened for arterial hypoxemia (PaO2 < 70 mm Hg) while they were seated, at rest, and breathing room air. Patients with arterial hypoxemia underwent contrast-enhanced two-dimensional echocardiography and pulmonary function testing. Hypoxemia (PaO2 < 70 mm Hg) was present in 7 of 54 patients (12.9%), although only 1 of them complained of dyspnea. The Childs classification of the patients were: A = 1, B = 4, and C = 1. All seven hypoxemic patients had positive contrast-enhanced two-dimensional echocardiography, consistent with hepatopulmonary syndrome. CONCLUSION The prevalence of hepatopulmonary syndrome in adult liver transplant candidates is elevated. The screening for hepatopulmonary syndrome should be part of the routine evaluation of liver transplant candidates even in the absence of pulmonary symptoms.

Comparação entre o custo do transplante hepático cadavérico e o intervivos

OBJECTIVE: To compare the cost of cadaveric liver transplantation with adult-adult right hepatic lobe living-donor transplantation. METHOD: Total cost of 25 cadaveric liver transplantations and 22 adult-adult right hepatic lobe living-donor transplantations was considered from the day of hospital admission until the day of discharge. Professional fees and expenses due to postransplant complications and donor follow-up were not included. RESULTS: There was no difference in hospital stay between recipients of cadaveric transplantation (13.2± 4.1 days) and those of living-donor transplantation (15.4± 4.5 days). Costs of living-donor organ acquisition (US

Transanal endoscopic microsurgery (TEM) in the treatment of postoperative colorectal stenosis

4,975.08± 565.34) were higher than those of cadaveric organ donation (US

Espectroscopia cerebral em candidatos a transplante hepático

3,081.73± 305.57) (p<0.001). Implantation costs were similar for cadaveric and living-donor transplantation. Operating room and material costs were higher for living-donor transplantation and medications, exams and blood components costs were higher for cadaveric transplantation. The most expensive component of both cadaveric and living-donor liver transplantation was the cost of medications. Total cost was higher for living-donor transplantation (US

Rotura hepática espontânea na síndrome HELLP

22,986.60± 1,477.09) than for cadaveric transplantation (US

Detecção da encefalopatia hepática subclínica por espectroscopia cerebral

21,582.90± 1,818.11) (p= 0.0022). CONCLUSIONS: Total cost of living-donor liver transplantation is higher than that of cadaveric transplantation.

Evaluation of healing prosthetic materials polyester mesh resorbable film and collagen elastin matrix /polypropylene used in rabbits abdominal wall defects

BACKGROUND: Strictures of low colorectal anastomosis are increasing by use the anastomotic stapler. There are many kinds of treatments like dilation, transanal rectotomy, and resection with linear or circular stapler. Other methods includes endoscopic knifes, absorbable sutures and laparotomy. The Transanal Endoscopic Microsurgery (TEM) has been used to treat postoperative anastomotic stenosis. CASES REPORT: Three cases of anastomotic strictures after low colorectal anastomosis were treated with TEM with success in medium follow-up. They had a good postoperative evolution without recurrence of symptoms and stenosis. CONCLUSION: The new TEM surgical approach seems to be a safe choice for the treatment of the postoperative colorectal stenosis.

Custo comparado da Microcirurgia Endoscópica Transanal (TEM) com a retossigmoidectomia anterior e com a cirurgia de amputação abdômino-perineal do reto

OBJECTIVES To determine the metabolite levels (myo-inositol [MI], choline [Cho], glutamate [Glx], creatine [Cr] and N-acetylaspartate [NAA]) visible on magnetic resonance spectroscopy in patients with chronic hepatic failure, before and after liver transplantation and to correlate these data with results of neuropsychiatric tests and clinical findings. METHODS Twenty five patients with chronic hepatic failure from the Liver Transplantation Unit of the Federal University of Parana were prospectively studied. Patients were submitted to clinical evaluation and magnetic resonance spectroscopy. Thirty healthy volunteers also submitted to the same evaluations. Sixteen of the 25 patients were evaluated after liver transplantation. RESULTS Before liver transplantation, significant reductions in MI/Cr and Cho/Cr and a significant increase in Glx/Cr were observed in patients with hepatic encephalopathy compared with healthy subjects. The Rosss criteria for spectroscopic diagnosis of the hepatic encephalopathy (MI/Cr and Cho/Cr lower than 2 SD of controls) demonstrated a sensitivity of 61.54%, specificity of 91.67% and accuracy of 76%, further Cho/Cr was the best parameter. Spectroscopy after liver transplantation showed changes in the metabolite ratios compared with the pretransplantation status. CONCLUSION Magnetic resonance spectroscopy permits an accurate diagnosis of hepatic encephalopathy. Improvement of metabolic ratios after liver transplantation suggests an important role of MI and Cho in the development of hepatic encephalopathy.

Anatomia das veias hepáticas em doadores e receptores de transplante hepático intervivos

INTRODUCAO: A sindrome HELLP, condicao com sinais de hemolise, elevacao de enzimas hepaticas e baixa contagem de plaquetas, e situacao obstetrica que pode apresentar severas complicacoes para a mae, incluindo hematoma subcapsular com risco de ruptura para a cavidade peritoneal. RELATO DO CASO: Um caso de ruptura espontânea do figado secundaria a sindrome HELLP e apresentado. A paciente foi submetida a laparotomia exploradora devido a choque hemorragico. CONCLUSAO: A sindrome HELLP e condicao patologica perigosa com risco de morte materno-fetal. Tratamento cirurgico deve ser indicado quando existe associacao a ruptura hepatica.