Jorge Eduardo Fouto Matias

A multivariate model to determine prognostic factors in gastrointestinal fistulas

BACKGROUND Some studies have identified and selected factors that were associated with prognosis in patients with gastrointestinal fistulas, but a multivariate analysis to determine their relative importance and independent predictive value has not been done. The aim of this study was to determine independent prognostic factors for fistula closure and death in patients with gastrointestinal fistulas using a multivariate model. STUDY DESIGN Several variables were assessed related to spontaneous closure, surgical closure, and mortality in 188 patients with digestive fistulas (duodenal 22.3%, jejunoileal 28.7%, colonic 23.9%, biliopancreatic 25%). Selection of the variables was done through a forward stepwise logistic regression procedure; the final models were used to estimate the probability of closure, either spontaneous or surgical, and the probability of death. RESULTS Variables significant for spontaneous closure were: cause of the fistula (p = 0.027), fistula output (p = 0.037), institutional origin of the patient (p = 0.026), and occurrence of complications (p<0.001). Organ of origin of the fistula was only marginally significant (p = 0.068). Successful surgical closure was significantly associated with the presence of complications (p = 0.001) and was marginally associated with age (p = 0.069). Variables significant for death were fistula output (p = 0.009) and the presence of complications (p<0.001). CONCLUSIONS We conclude that the likelihood of spontaneous fistula closure is higher for fistulas with surgical causes, low output, and with no complications. Mortality is higher in patients with complications and with high-output fistulas.

Nutritional aspects of liver transplantation.

Most adult and pediatric liver transplantation candidates present several metabolic disturbances that lead to malnutrition. Because malnutrition may adversely affect morbidity and mortality of orthotopic liver transplantation, it is very important to carefully assess the nutritional status of the waiting list patients. Pretransplant nutritional therapy - enteral or parenteral - may positively influence liver metabolism, muscle function, and immune status. Nutrition therapy should continue in the short- and also in the long-term post-transplant periods. For malnourished patients, early post-transplant enteral or parenteral nutrition have been useful in improving nutritional status. Finally, the metabolic and nutritional care of the liver transplant donor must be considered to reduce allograft dysfunction indices.

Donor Complications Including the Report of One Death in Right-Lobe Living-Donor Liver Transplantation

Background/Aims: Our objective is to assess donor complications in all right hepatic lobe living-donor liver transplantation (LDLT) at our center. Methods: Of a total of 352 liver transplantations performed, 60 were right-lobe LDLT. Most donors (88.3%) were related to the recipients. Results: Mean hospital stay was 5.4 8 0.6 days. No complications occurred due to preoperative evaluation. Most donors received one or two units of autologous blood transfusion. Only 5 (8.3%) needed nonautologous blood transfusion. Most complications were minor and treated conservatively. Bile leaks from the cut surface of the liver occurred in 5 donors (8.3%). Two patients had potentially fatal complications: perforated duodenal ulcer and portal vein thrombosis (PVT). The donor with perforated ulcer developed septicemia and multiple organ failure. He was discharged from the hospital with hemiparesis due to cerebral ischemia. The patient with PVT remained asymptomatic and the portal vein was recanalized by the 3rd postoperative month. One donor died in the immediate postoperative period of cardiac arrest due to cardiac arrhythmia. Conclusion: Right hepatectomy for LDLT may be associated with significant morbidity, including death and it should be performed only by surgeons with great experience.

Acao do extrato de Jatropha gossypiifolia L. (piao roxo) na cicatrizacao de anastomose colonica: estudo experimental em ratos

INTRODUCTION: Phytotherapy has been drawing interest from the scientific community regarding its potential wound healing properties. There are few studies available that present a correct scientific methodology and, therefore, phytotherapy remains an open field for further research. PURPOSE: To evaluate the effects of Jatropha gossypiifolia L. (bellyache bush) on the healing of colonic anastomosis in rats. METHODS: Forty Wistar rats were subjected to a complete section of the colon, that was soon sutured with eight separate stitches using monofilament polipropilene 6-0. Randomly, the animals were divided into control group (CG), with 20 rats, which were injected with 0.9% sodium chloride solution intraperitoneally (1mL/kg) and Jatropha group (JG), also with 20 rats, which were injected with Jatropha gossypiifolia L. alcoholic extract intraperitoneally (1mL/kg). Each of the groups was subdivided into two subgroups of ten rats, according to the sacrifice date, third and seventh days (CG3/ CG7 and JG3/ JG7). After sacrifice, the segment of the colon containing 1cm proximal and distal to the site of anastomosis was removed and subjected to the pressure test with air insuflation. This segment was then opened and a 1.0 x 0.5cm part was removed and placed under 10% formaldehyde for histological analysis with hematoxylin-eosin and Massons trichrome stainings. RESULTS: The evaluation of the pressure rupture test demonstrated statistical significance regarding the sacrifice date. On the third day, the average pressure of the CG (25,4mmHg) and the JG (76,4mHg) revealed p = 0.013, and on the seventh day, the average pressure of the CG (187,3 mmHg.) and the JG (135,1 mmHg.) revealed p = 0.014. When assessing the microscopic variables among the groups of the 3rd day, only the variables edema and polymorphonuclear cells did not show statistical differences. On the 7th day, all of the variables assessed demonstrated significant differences. CONCLUSIONS: Regarding mechanical resistance, there was a difference in resistance between the JG3 and the CG3, and a shift of resistance when comparing the JG7 and CG7, which suggests a weakening of the Jatropha effect at a later stage of healing. The histological evaluation revealed an improvement of the acute inflammatory process in the JG3 when compared to the CG3, which was even more intense during the chronic stage, when the two groups are compared on the seventh day. The histological study of the inflammatory process, in general, showed a favorable effect to the Jatropha group compared to the control group.INTRODUCTION Phytotherapy has been drawing interest from the scientific community regarding its potential wound healing properties. There are few studies available that present a correct scientific methodology and, therefore, phytotherapy remains an open field for further research. PURPOSE To evaluate the effects of Jatropha gossypiifolia L. (bellyache bush) on the healing of colonic anastomosis in rats. METHODS Forty Wistar rats were subjected to a complete section of the colon, that was soon sutured with eight separate stitches using monofilament polypropylene 6-0. Randomly, the animals were divided into control group (CG), with 20 rats, which were injected with 0.9% sodium chloride solution intraperitoneally (1 mL/kg) and Jatropha group (JG), also with 20 rats, which were injected with Jatropha gossypiifolia L. alcoholic extract intraperitoneally (1 mL/kg). Each of the groups was subdivided into two subgroups of ten rats, according to the sacrifice date, third and seventh days (CG3/ CG7 and JG3/ JG7). After sacrifice, the segment of the colon containing 1cm proximal and distal to the site of anastomosis was removed and subjected to the pressure test with air insulation. This segment was then opened and a 1.0 x 0.5 cm part was removed and placed under 10% formaldehyde for histological analysis with hematoxylin-eosin and Massons trichrome stainings. RESULTS The evaluation of the pressure rupture test demonstrated statistical significance regarding the sacrifice date. On the third day, the average pressure of the CG (25.4 mmHg) and the JG (76.4 mmHg) revealed p = 0.013, and on the seventh day, the average pressure of the CG (187,3 mmHg.) and the JG (135.1 mmHg.) revealed p = 0.014. When assessing the microscopic variables among the groups of the 3rd day, only the variables edema and polymorphonuclear cells did not show statistical differences. On the 7th day, all of the variables assessed demonstrated significant differences. CONCLUSIONS Regarding mechanical resistance, there was a difference in resistance between the JG3 and the CG3, and a shift of resistance when comparing the JG7 and CG7, which suggests a weakening of the Jatropha effect at a later stage of healing. The histological evaluation revealed an improvement of the acute inflammatory process in the JG3 when compared to the CG3, which was even more intense during the chronic stage, when the two groups are compared on the seventh day. The histological study of the inflammatory process, in general, showed a favorable effect to the Jatropha group compared to the control group.

Effect of watery extract of Orbignya phalerata (babassu) in the gastric healing in rats: morfologic and tensiometric study

ABSTRACT Introduction : The large use of plants in the prevention and treatment of different diseases is a milenar practice. In Brazil due to it’s rich flora there is a huge material for research and use in popular medicine. The babassu ( Orbignya phalerata ) is a native tree from North of the Brazil and has a high concentration at the State of Maranhao. The powder of it’s mesocarp is known as amid, and has been used as meal and medication due to the known activity against antiflammatory reaction, pain, pyrexia and immunomodulation. Purpose: To analyze the effect of mesocarp of Orbignya phalerata (babassu) in gastric wound healing in rats under morphologic and tensiometric aspects. Method: Forty Wistar rats, male, adults were submitted to a longitudinal incision of 1 cm in the gastric body and sutured with separated stitches of polypropilene 6.0. After this common procedure the animals were allocated in the aleatory way in two groups Orbignya (GO) and Control (GC) with 20 animals each one. In the GO was used intraperitoneal doses of 50mg/kh of

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.

Insulin-like growth factor I correlates with MELD and returns to normal level after liver transplantation

BACKGROUND Insulin-like growth factor I (IGF-I) is produced almost entirely by the liver and is the main promoter of anabolic growth hormone (GH) effects on protein, carbohydrate, and lipid metabolism. IGF-I is significantly decreased in patients with liver cirrhosis. Our objective was to determine the relationship between circulating IGF-I and MELD (Model for End-stage Liver Disease) in cirrhotics subjected to orthotopic liver transplantation (OLT). We also assessed the changes of IGF-I and its major binding protein (IGF-binding protein-3 or IGFBP-3) after OLT. MATERIAL AND METHODS In a prospective study, serum levels of IGF-I and IGFBP-3 of 25 male adult patients with end-stage liver disease were measured 2 to 4 hours before and 6 months after orthotopic liver transplantation. Seven age-matched healthy male volunteers with normal liver enzymes, albumin, and prothrombin time served as controls. MELD was determined on the day of OLT. For this analysis, extra points were not added for patients with hepatocarcinoma. RESULTS The cirrhotic group had significantly lower IGF-I (46.7±21.6 ng/mL) and IGFBP-3 (1.0±0.9 ng/mL) levels in the pre-transplant period compared with the controls (208.6±76.5 ng/mL and 4.62±0.93 ng/mL, respectively) (p<0.05). There was a negative correlation between IGF-I or IGFBP-3 and MELD (p<0.001) (ß=-1.750; standard error =2.5054 and ß=-0.038; standard error <0.0001, respectively). IGF-I e IGFBP-3 increased to normal levels after OLT (207.7±82.8 and 4.14±1.1 ng/mL, respectively) (p<0.001). CONCLUSIONS Low levels of IGF-I and IGFBP-3 observed in patients with advanced liver cirrhosis are corrected after OLT. IGF-I and IGFBP-3 correlate negatively with MELD.

Effect of pantoprazole administered subcutaneously on the healing of sutured gastric incisions in rats

Background: The properties of proton pump inhibitors most investigated are related to peptic diseases and upper gastrointestinal bleeding, but their influence on the healing of sutured gastric incisions has not been assessed. In the present study we evaluated the effect of subcutaneously administered pantoprazole on the healing of sutured gastric incisions in rats. Methods: Sixty rats were divided into a pantoprazole group and a control group. All rats were submitted to gastric suture in the gastric body and in the gastric fundus and had their gastric pH measured. The pantoprazole group received 20 mg/kg pantoprazole and the control group received 0.9% isotonic NaCl, both subcutaneously t.i.d. Healing analysis was carried out using collagen picrosirius red F3BA staining, and breaking strength was measured on the 4th and 7th postoperative days in all groups. Results: Gastric pH was higher in the pantoprazole group. In the fundus, the pantoprazole group had a higher measurement of breaking strength and a higher proportion of type-I over type-III collagen on the 7th postoperative day. In the body, the pantoprazole group had a higher proportion of type-I over type-III collagen on the 4th and 7th postoperative days. Conclusions: Pantoprazole given subcutaneously promoted a reduction in gastric acid secretion and was associated with improved healing of the sutured gastric incision in the fundus (squamous epithelium) of rats. These findings suggest that pantoprazole has healing properties in sutured gastric incisions with potential benefits in gastric surgery.

The influence of estrogen on liver regeneration: an experimental study in rats

PURPOSE To recognize the regenerative capacity influenced by the administration of estradiol. METHODS 42 female Wistar rats were used, divided into two groups, the control and the experiment group. A resection of approximately 70% of the liver was made in the liver of these animals. The control group received an intramuscular injection of one ml of peanut oil. The experiment group were given estradiol hexahydrobenzoate (50 microg) diluted in one ml of peanut oil. Calibrations were done after 36 hours and 7 days, using three methods: the formula of Kwon et al.21, to recognize gain in volume, counting of the mitosis figures in five fields and the percentage of positive PCNA nuclei. RESULTS Gain in volume (mass) was similar in both groups after 36 hours (p=0.1873) and higher in the experiment groups after seven days (p=0.0447). Microscopy showed a similar number of mitosis figures after 36 hours (p=0.3528) and a tendency to be higher in the experiment group after 7 days (p=0.0883). The average of positive PCNA nuclei was higher in the experiment group both after 36 hours (p=0.0009) and 7 days (p=0.0000). CONCLUSION The estradiol hexahydrobenzoate improved liver regeneration in rats submitted to a 70% hepatectomy.

Função sexual de homens submetidos a transplante hepático

BACKGROUND: Sexual dysfunction is very common in liver transplantation candidates. Our objective is to determine the sexual life quality of males before and after liver transplantation. METHODS: Questionnaire was sent to 56 males over 18 years of age with at least six-month survival after orthotopic liver transplantation. The self-administered questionnaire contained 15 questions with 5 or 6 alternatives to determine the male sexual function which may be divided into 5 domains: 1) erectile function; 2) orgasmic function; 3) sexual desire; 4) intercourse satisfaction; and 5) overall satisfaction with sexual life. Each answer received a score. Domains scores were computed by summing the scores for individual answers and they were compared before and after the liver transplantation. RESULTS: Twenty-five patients answered the questionnaire completely. All 5 sexual function domains improved after liver transplantation. The score of the erectile function increased from 21.12± 8.07 to 26.52± 5.22 (p=0.004), of the orgasmic function from 7.28± 3.05 to 9.36± 1.47 (p=0.008), of the sexual desire from 6.64± 2.58 to 8.68± 1.35 (p=0.005), of intercourse satisfaction from 9.16± 3.83 to 12.52± 2.65 (p<0.0001) and of overall satisfaction from 7.12± 2.64 to 9.24± 1.65 (p=0.002). CONCLUSIONS: Sexual dysfunction is common in males with severe chronic liver disease and liver transplantation improves all sexual function domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction.BACKGROUND Sexual dysfunction is very common in liver transplantation candidates. Our objective is to determine the sexual life quality of males before and after liver transplantation. METHODS Questionnaire was sent to 56 males over 18 years of age with at least six-month survival after orthotopic liver transplantation. The self-administered questionnaire contained 15 questions with 5 or 6 alternatives to determine the male sexual function which may be divided into 5 domains: 1) erectile function; 2) orgasmic function; 3) sexual desire; 4) intercourse satisfaction; and 5) overall satisfaction with sexual life. Each answer received a score. Domains scores were computed by summing the scores for individual answers and they were compared before and after the liver transplantation. RESULTS Twenty-five patients answered the questionnaire completely. All 5 sexual function domains improved after liver transplantation. The score of the erectile function increased from 21.12 +/- 8.07 to 26.52 +/- 5.22 (p=0.004), of the orgasmic function from 7.28 +/- 3.05 to 9.36 +/- 1.47 (p=0.008), of the sexual desire from 6.64 +/- 2.58 to 8.68 +/- 1.35 (p=0.005), of intercourse satisfaction from 9.16 +/- 3.83 to 12.52 +/- 2.65 (p<0.0001) and of overall satisfaction from 7.12 +/- 2.64 to 9.24 +/- 1.65 (p=0.002). CONCLUSIONS Sexual dysfunction is common in males with severe chronic liver disease and liver transplantation improves all sexual function domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction.