Henrique Bicha Castelo

Acute Kidney Injury after Major Abdominal Surgery: A Retrospective Cohort Analysis

Background. We analyzed the incidence, risk factors, and prognosis of acute kidney injury (AKI) in a cohort of patients undergoing major abdominal surgery. Methods. A total of 450 patients were retrospectively studied. AKI was defined by an increase in serum creatinine (SCr) ≥ 0.3 mg/dl or by an increase in SCr ≥ 50% and/or by a decrease in urine output to 0.5 ml/kg/hour for 6 hours, in the first 48 hours after surgery. Logistic regression method was used to determine predictors of AKI and in-hospital mortality. A two-tailed P value <0.05 was considered significant. Results. One hundred one patients (22.4%) had postoperative AKI. Age (adjusted odds ratio (OR) 1.02, 95% confidence interval (CI) 1.01–1.05), nonrenal Revised Cardiac Risk Index score (adjusted OR 1.9, 95% CI 1.3–3.1, P = 0.003), intraoperative erythrocytes transfusions (adjusted OR 2.2, 95% CI 1.4–3.5, P <.0001), and nonrenal Simplified Acute Physiology Score II (adjusted OR 1.03, 95% CI 1.01–1.06, P = 0.0191) were associated with postoperative AKI. AKI was associated with increased in-hospital mortality (20.8% versus 2.3%, P <.0001; unadjusted OR 11.2, 95% CI 4.8–26.2, P <.0001; adjusted OR 3.7, 95% CI 1.2–11.7, P = 0.024). Conclusion. AKI was common in patients undergoing major abdominal surgery and was associated with in-hospital mortality.

Carcinoid Heart Disease: Outcome After Balloon Pulmonary Valvuloplasty

Carcinoid heart disease typically presents with pulmonary stenosis and tricuspid regurgitation. Management is intended for symptomatic relief, and valvular intervention is indicated in refractory heart failure. Balloon valvuloplasty is an option for patients not suitable for surgery. We report the case of a patient with a carcinoid tumour, who developed postoperative refractory hypoxemia. Transthoracic echocardiogram revealed carcinoid pulmonary and tricuspid valve disease, with severe pulmonary stenosis. Balloon valvuloplasty was performed with major clinical improvement.

Total gastrectomy in an elderly patient complicated by esophageal fistula: rescue by the over-the-scope clip.

Commentary I have seen many aspirations in the endoscopy suite: blood, a polyp that was resected and dropped while being removed, a fibrovascular polyp that was regurgitated and took the wrong path when being reswallowed, a foreign body, food particles, and, the only good one of course, young endoscopists whose aspirations are to be like their mentors. This case I believe is unique: essentially a piece of normal esophageal wall that was firmly adherent to an SEMS and stripped off as a complication of a forced stent removal with a pair of rat-toothed forceps. Fortunately, the patient experienced stridor, and the complication was recognized promptly, only to present again 2 months later as a stricture. James A. Owen, author of The Barbizon Diaries: A Meditation on Will, Purpose, and the Value of Stories, said, “Bad things can happen, and often do— but they only take up a few pages of your story; and anyone can survive a few pages.” I think this patient’s story will continue for many more pages, and ultimately, I hope his story has a happy ending. Lawrence J. Brandt, MD Associate Editor for Focal Points

Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas

Background and Aims: Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas. Methods: This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence. Results: The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4–145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1–10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15–72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50–205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence. Conclusions: A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically. Key Messages: Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.

Self-Regulation of Weight After Sleeve Gastrectomy:

Bariatric surgery is recognized as the most effective method for achieving relevant weight loss in subjects with severe obesity. However, there is insufficient knowledge about weight self-regulation and quality of motivation in these patients. The main goal of this study was to characterize the association between the percentage of excess weight loss (%EWL) and the motivation to manage weight, at least 1 year after sleeve gastrectomy (SG). This is an observational longitudinal retrospective study. All patients corresponding to predefined inclusion criteria who underwent SG from January 2008 to July 2010 at a main general hospital were invited. A version of the Treatment Self-Regulation Questionnaire (TSRQ) was used to assess patients’ quality of motivation: TSRQ concerning continuing the weight self-management program. Clinical data were collected from patients’ records. Overall, 81 patients participated (16 men and 65 women, 25-64 years old). The average body mass index was significantly reduced from 45.3 ± 7.0 kg/m2 preoperatively to 32.7 ± 6.9 kg/m2 postoperatively. Autonomous self-regulation was higher than externally controlled self-regulation, regarding motives to keep managing weight after SG. Postoperatively, %EWL correlated negatively with external self-regulation. SG was found to be associated with the quality of motivation for losing weight. External motivations were associated with worse results. These findings support the importance of multiprofessional teams in the assessment and treatment of patients, aiming for the promotion of weight self-regulation after bariatric surgery.

Reversibilidade da miocardiopatia induzida por catecolaminas associada ao feocromocitoma

Pheochromocytoma is a tumor originating from chromaffin tissue. It commonly presents with symptoms and signs of catecholamine excess, such as hypertension, tachycardia, headache and sweating. Cardiovascular manifestations include catecholamine-induced cardiomyopathy, which may present as severe left ventricular dysfunction and congestive heart failure. We report a case of pheochromocytoma which was diagnosed following investigation of dilated cardiomyopathy. We highlight the dramatic symptomatic improvement and reversal of cardiomyopathy, with recovery of left ventricular function after treatment.