José Roberto Alves

IMMEDIATE COMPLICATIONS AFTER 88 HEPATECTOMIES - BRAZILIAN CONSECUTIVE SERIES

ABSTRACT Background: Hepatectomies have been increasingly recommended and performed in Brazil; they present great differences related to immediate complications. Aim: Assessing the immediate postoperative complications in a series of 88 open liver resections. Method: Prospective database of patients subjected to consecutive hepatectomies over nine years. The post-hepatectomy complications were categorized according to the Clavien-Dindo classification; complications presenting grade equal to or greater than 3 were considered major complications. Hepatic resections involving three or more resected liver segments were considered major hepatectomies. Results: Eighty-four patients were subjected to 88 hepatectomies, mostly were minor liver resections (50 cases, 56.8%). Most patients had malignant diseases (63 cases; 71.6%). The mean hospitalization time was 10.9 days (4-43). Overall morbidity and mortality rates were 37.5% and 6.8%, respectively. The two most common immediate general complications were intra-peritoneal collections (12.5%) and pleural effusion (12.5%). Bleeding, biliary fistula and liver failure were identified in 6.8%, 4.5% and 1.1% of the cases, respectively, among the hepatectomy-specific complications. Conclusion: The patients operated in the second half of the series showed better results, which were apparently influenced by the increased surgical expertise, by the modification of the hepatic parenchyma section method and by the increased organ preservation.

MICROBIOLOGICAL ANALYSIS OF BILE IN PATIENTS WITH BENIGN AND MALIGNANT BILIOPANCREATIC DISEASES AND ITS CONSEQUENCES

BACKGROUND Bactibilia has several consequences to human health. OBJETIVE Assessing the bile microbiology of patients with biliopancreatic diseases in order to identify bacteria and their possible infectious complications. METHODS Retrospective study of 30 bile culture samples from patients with benign and malignant biliopancreatic diseases. The samples were assessed to set the bile microbiological flora and to search for its possible link with comorbidity, carcinogenesis and postoperative infectious complications. RESULTS Thirty bile samples from patients at mean age ≈57.7 years, mostly female (n=18), were assessed. Bactibilia was found in 12 cases, mostly in patients with benign diseases (n=8), older than 50 years (n=23) and female (n=10). Adenocarcinoma of the duodenal papilla (n=9) and cholelithiasis (n=8) were the most common diseases. Escherichia coli (n=5) and Klebsiella sp (n=3) were predominantly found in patients with benign diseases; and Klebsiella sp (n=2) and Streptococcus sp (n=2) were prevalent in cancer patients. There were postoperative infectious complications in seven cases, five of them in bactibilia-associated patients (P=0.084). CONCLUSION Bactibilia was found in 12 samples and Escherichia coli and Klebsiella sp were most often identified in patients with benign diseases, as well as Streptococcus sp and Klebsiella sp in cancer patients. There was a trend of higher postoperative infectious complication incidence in patients with bactibilia.

Splenic vein graft for the reconstruction of the mesenteric-portal trunk after gastroduodenopancreatectomy

Resection of the confluence of the superior mesenteric and portal veins has been performed most frequently in the treatment of adenocarcinoma of the pancreas, in view of the reported positive results, but it can also be used in cases of benign pancreatic neolpasias when they are strongly adhered to the mesenteric-portal trunk. Nevertheless, there is no study on the best type of venous grafts for reconstruction of the mesenteric-portal trunk when required. The choice of graft depends on the preference of the surgeon or the institution. This technical note critically discusses the use of the splenic vein as an option for mesenteric-portal trunk reconstruction after gastroduodenopancreatectomy.

Solid-Pseudopapillary Neoplasm of the Pancreas: Case Series and Literature Review

The solid-pseudopapillary neoplasm of the pancreas is a rare disease, although since 2000, it has been often identified. The current study aims to present a 10-case series of solid-pseudopapillary neoplasm of the pancreas and a literature review on the topic. The cohort consisted of nine female patients and one male. The mean age in the group was 31.2 year-old. These patients underwent surgical treatment at the University Hospital between May 2007 and July 2014. Since there was a previous systematic literature review on solid-pseudopapillary neoplasm of the pancreas (prior to September 20 th , 2012), a complementary review was done after this period using PubMed’s data base. The search identified 225 studies on this subject, but only 13 were selected for detailed analysis, after applying the inclusion and exclusion criteria. As a result, most of the information about the disease’s epidemiology, clinical manifestations, malignity risk factors, metastasis and relapse were gathered, however, early diagnosis remained a challenge. Radical surgical resection is established as the standard treatment protocol for the disease, it is also recommended to perform metastasectomy, vascular resections and/or resections of other compromised organs in order to ensure therapeutic success in 95% of the cases. However, a post-operative follow up of at least 5 years is required to identify the possibility of relapses. Further studies are still needed mainly to define this disease’s true prevalence among men, protocols for early diagnosis and the possible role of adjuvant therapies. Image: Intraoperative picture demonstrating a SPN in pancreatic head attached to the portal vein.

HYPERVASCULAR LIVER LESIONS IN RADIOLOGICALLY NORMAL LIVER

ABSTRACT Background: The hypervascular liver lesions represent a diagnostic challenge. Aim: To identify risk factors for cancer in patients with non-hemangiomatous hypervascular hepatic lesions in radiologically normal liver. Method: This prospective study included patients with hypervascular liver lesions in radiologically normal liver. The diagnosis was made by biopsy or was presumed on the basis of radiologic stability in follow-up period of one year. Cirrhosis or patients with typical imaging characteristics of haemangioma were excluded. Results: Eighty-eight patients were included. The average age was 42.4. The lesions were unique and were between 2-5 cm in size in most cases. Liver biopsy was performed in approximately 1/3 of cases. The lesions were benign or most likely benign in 81.8%, while cancer was diagnosed in 12.5% of cases. Univariate analysis showed that age >45 years (p< 0.001), personal history of cancer (p=0.020), presence of >3 nodules (p=0.003) and elevated alkaline phosphatase (p=0.013) were significant risk factors for cancer. Conclusion: It is safe to observe hypervascular liver lesions in normal liver in patients up to 45 years, normal alanine aminotransaminase, up to three nodules and no personal history of cancer. Lesion biopsies are safe in patients with atypical lesions and define the treatment to be established for most of these patients.

Morphometric Study in Stomach of Rabbits

Treinta y tres conejos, neozelandeses, sanos, se sometieron a una gastrectomia total por laparotomia y posterior evaluacion de las dimensiones gastricas. Se midio la longitud de las curvaturas gastricas menor y mayor y el diametro mayor del organo. La longitud total promedio de las curvaturas menor y mayor fue de 6,7 cm y 27,3 cm, respectivamente. La zona quirurgica abierta presentada 172,6 cm2. Segun la edad y para hacer comparaciones entre el peso y las medidas gastricas la muestra se dividio en dos grupos. Grupo 1 animales con menos de 138 dias y grupo 2 animales que tenian mas de 138 dias. No se encontraron diferencias significativas entre los grupos. Esto puede sugerir que para el entrenamiento quirurgico el uso de animales mas jovenes puede ser llevado a cabo en los protocolos. Finalmente, se observo en todos los animales predominio de la arteria gastrica izquierda en la irrigacion de la pared gastrica y la presencia de una fina capa peritoneal transparente entre el higado y el estomago.