Luiz Sergio Leonardi

Intraoperative Massive Transfusion Decreases Survival After Liver Transplantation

Patients undergoing liver transplantation often experience coagulopathy and massive intraoperative blood loss that can lead to morbidity and reduced survival. The aim of this study was to verify the survival rate and discover predictive factors for death among liver transplant patients who received massive intraoperative blood transfusions. This cohort study was based on prospective data collected retrospectively from January 2004 to July 2006. The 232 patients were distributed according to their blood requirements, (namely, more or less than 6 units), including red blood cell saver. The statistical analyses were performed using Student t test, Cox hazard regression, and the Kaplan-Meier method (log-rank test). The massively transfused cohort displayed higher Child-Pugh classifications (10.2 vs 9.6; P = .03); model for end-stage liver disease (MELD) scores (19 vs 17; P = .02); recipient weights (75.4 vs 71 kg; P = .03); as well as warm ischemia times (70.7 vs 56.4 minutes; P < .001) and surgery times (584.6 vs 503.4 minutes; P < .05). The proportional hazard (Cox) regression analysis showed that the risk of death increased 2.1% for each unit of donor sodium and 1.6% for each additional year of donors age over 50. The survival rates at 6, 12, 60, and 120 months for > or = 6 vs <6 U of blood transfusion of 63.8% vs 83.3%; 53.9% vs 76.3%; 40% vs 60%; 34.5% vs 49.2%. In conclusion, we observed that patients receiving over 6 red blood cell units intraoperatively displayed reduced survival. Predictive factors for this risk factor were high donor level of sodium and of age.

Tratamento conservador das estenoses benignas do esôfago através de dilatações. Análise de 500 casos

The benign esophageal stenoses (BES) are common complications owing to many etiologies: gastroesophageal reflux, ingestion of corrosive agents, esophageal surgery, radiotherapy, postendoscopic variceal sclerotherapy, drug ingestion, prolonged nasogastric intubation, extrinsic compression and esophageal webs. Esophageal dilatations are worldwide recommended to treat this complication, employing dilators of many types and diameters and facilitating the food ingestion. PURPOSE: Evaluation of the results and advantages of the conservative treatment of the BES using esophageal dilatations, in outpatient service of upper digestive endoscopy. METHODS: During the period from 1981 to 1999, 500 patients with BES were treated and followed up at the Gastrocenter ¾ UNICAMP, in an individually Program of Esophageal Dilatation for each case. The highest number of cases was under ages from 31 to 60 years old (52,8%), and males (59,2%). The most predominant etiologies were: peptic stenosis (30,4%), caustic ingestion (23,6%), anastomosis (23,2%), megaesophagus (8,0%) and prolonged nasogastric ingestion entubation (6,4%), totalizing 91,6% of the BES. Most of patients (94,2%) were submitted to the maximum of 25 dilations. Dilators from 10,5 to 16 mm were employed in 95,6% of the cases. The duration of the treatment was 24 months in 76,2% of the BES. Esophageal perforations occurred in 6 patients (1,2%), without mortality. RESULTS: Were considered excellent, good and bad results, respectively in 76,2%, 18,2% and 5,6% of the cases. On the other hand, excellent results were recorded in 81,0% of the peptic stenosis, 66,1% of the caustic stenosis and 82,7% of the anastomotic stenosis. The conservative treatment failed in 9,3% of the caustic stenosis, 4,3% of the anastomotic stenosis and 3,9% of the peptic stenosis. Thus, the caustic stenosis were unsuccessfull in the highest percentage of unsuccessful. CONCLUSION: The conservative treatment using guidewire dilators (Savary-Gilliard and Eder-Puestow) is the first choice in the BES, is effective for long time, with short complications and the surgical treatment is indicated only when the dilatations failed.

Tratamento cirurgico videolaparoscopio da doença de refluxo gastroesofagiano : tecnica de Nissen modificada - resultados clinicos e funcionais

A doenca do refluxo gastroesofagiano, em funcao de acometer grande parte da populacao, dos avancos no conhecimento da fisiopatologia da doenca, das novas drogas disponiveis para o tratamento clinico e do desenvolvimento no campo do tratamento cirurgico, com o advento da videocirurgia laparoscopica, sua importância e evidente na sociedade. O tratamento empregado, quer clinico ou cirurgico, deve alcancar a eliminacao dos sintomas e a correcao defmitiva dos fatores que propiciam o refluxo, o que e obtido na maioria das vezes, com a cirurgia. Um grupo de 59 pacientes, com diagnostico de doenca do refluxo gastroesofagiano, foi submetido a tratamento cirurgico pela tecnica de Nissen bmodificada por videolaparoscopia. O tempo medio de historia previa de sintomas foi de 77,4 meses e todos tinham sido submetidos a varios tratamentos clinicos anteriores. O sexo feminino predominou com 54,2% e a idade variou de 15 a 82 anos, com media de 52,5 anos. O diagnostico pre-operatorio foi suspeitado por avaliacao clinica, e confirmado por exame radiografico contrastado e endoscopia em todos os pacientes. A manometria do esofago foi realizada em 35 pacientes e a cintilografia, em 15. O diagnostico de esofagite nao cOmplicada ocorreu em 27 doentes (45,8%) e de esofagite complicada, em 32 deles (54,2%). O epitelio de Barrett foi encontrado em 21 pacientes (35,6%). A tecnica empregada por videolaparoscopia foi possivel em todos os pacientes e sem necessidade de conversao para cirurgia aberta. O tempo medio para a realizacao da cirurgia foi de 123,9 minutos. A colecistectomia foi realizada concomitantemente em nove doentes (15,5%). Um paciente apresentou ulcera duodenal com estenose e diverticulo de Zenker tratados no mesmo ato cirurgico. Nao ocorreram complicacoes intra-operatorias e um obito (1,7%) ocorreu no pos-operatorio precoce devido a necrose parcial do fundo gastrico. A alta hospitalar ocorreu em media com 47,6 horas. Os sintomas imediatos de disfagia, dor, epigastralgia, regurgitacao, flatulencia e um caso de pneumonia ate o 30° dia de pos-operatorio, ocorreram em 48,1% dos pacientes, com resolucao espontânea na maioria deles. O seguimento pos-operatorio medio foi de 20,8 meses. Em media, 10% dos pacientes referiram sintomas de regurgitacao, pirose ou disfagia, com melhora no decorrer do tempo. Houve uma (1,7%) reoperacao tardia por esofagite e estenose, sendo Fea1izado gastrectomia Y -Roux. Observou-se flatulencia em 5,3% dos pacientes. Os examespos-operatorios radiograficos foram realizados em 39 pacientes, a endoscopia, em 53, a manometri3!, em 35 e a cintilografia, em 40. Diagnosticou-se hernia paraesofagiana em 5% dos exames. A maioria dos dados analisados nos exames, em comparacao com o pre-operatorio, mostraraml melhora acentuada. A classificacao de Visick mostrou que 93,10% tiveram resultados excelentes e bons, independente do grau da esofagite no pre-operatorio. A analise comparativa entre a avaliacao clinica pre e pos-operatoria, e os resultados dos exames complementares pre e pos-operatorios, permitiu concluir que, a cirur.gia de Nissen modificada por videolaparoscopia, corrigiu a doenca do refluxo gastroesofagiano na maioria dos doentes acompanhados Abstract

Elderly Donors for HCV+ Versus Non-HCV Recipients: Patient Survival Following Liver Transplantation

INTRODUCTION Chronic liver failure due to hepatitis C virus (HCV)-related cirrhosis is the leading indication for liver transplantation. Inferior long-term results have been reported for liver transplantation in HCV(+) patients, especially when marginal donor livers are utilized. AIM The aim of this study was to analyze retrospectively the outcome of liver transplantation patients from elderly donors in the case of HCV(+) versus non-HCV recipients. METHODS Among 330 liver transplantations performed from January 1994 to December 2006, we selected 244 excluding acute hepatic failure, children, and retransplants. Among these patients we analyzed 232 subjects who underwent the piggyback technique. Donor risk index (DRI) as described by Feng et al was applied using 1.7 as a cutoff value. We used Kaplan-Meier survival and Cox hazard regression analyses. We studied 14 donor variables using descriptive statistical tests. RESULTS There were 148 (63.8%) HCV(+) recipients and 84 (36.2%) non-HCV liver transplant recipients. Among HCV(+) recipients, 130/148 (87.8%) patients received livers, from donors less than 50 years old, and 18/148 (12.2%), over 50 years. The descriptive statistics of patient categorical variables are shown in Table 1, and continuous variables in Table 2. The cumulative proportional survival curves are shown in Figs 1 and 2. Mortality predictive factors in HCV(+) liver transplant recipients with donor age > 50 years old as determined by Cox hazard regression showed that death risk was increased with hazard ratios for warm ischemia = 1.01 (P = .001); for red blood cell intraoperative requirements = 2.63 (P = .003); for Child-Turcotte-Pugh classification points = 2.25 (P = .04), and for DRI > 1.7 = 2.19 (P = .03). In conclusion, advancing donor age, as well as the use of nonideal donors, intraoperative bleeding, and prolonged warm ischemia, had an adverse influence on patient survival for HCV(+) recipients.

Extragastrointestinal Stromal Tumor and Liver Transplantation : Case Report and Review

The occurrence of de novo malignant neoplasias has been shown in postransplant patients under imunosuppression. It is the second leading cause of late death in liver transplant recipients. The greatest incidence is seen in cancers associated with chronic infection by human papilloma virus, skin cancers, oropharyngeal, and gastrointestinal (GI) malignancies. GI stromal tumors (GISTs) are the most common mesenchymal tumors of the GI tract. Rare cases are identified outside the GI tract are collectively known as extragastrointestinal stromal tumors (EGISTs). We present an EGIST case in a liver transplantation patient. A 64-year-old man underwent liver transplantation because of cirrhosis (hepatitis B virus and alcoholism) and hepatocellular carcinoma. Histopathologic findings revealed 2 trabecular hepatocellular carcinomas: a 3.5-cm-diameter lesion located at segment VIII and another 2-cm one at segment V. Seven months later, he noticed a hardened, mobile, painless, 3-cm subcutaneous nodule in the perineum localized in the right lateral quadrant 2 cm distant from the anus. A surgical resection with 1 cm margin yielded a histopathology report of a 5.0 x 3.0 cm spindle cell stromal tumor. The immunohistochemical profile was compatible with a GIST, with 5 mitosis per 50 high-powered fields. This tumor is extremely rare after liver transplantation but has shown a good outcome up to now.

Avaliação tardia de doentes gastrectomizados por úlcera péptica: aspectos clínicos, endoscópicos e histopatológicos

BACKGROUND The gastrectomy is an uncommon procedure because the proton bomb inhibitors associated to the antibiotic outlines used to eradicate the Helicobacter pylori changed the focus of the peptic ulcer treatment. AIMS Later evaluation on those patients who underwent partial gastrectomy as a treatment for peptic ulcer, at that time when any drug to eradicate the Helicobacter pylori was not used. The clinical evaluation included the late postoperative symptoms and postgastrectomy syndromes like dumping, diarrhea, alkaline gastritis and nutritional aspects. The upper digestive endoscopy analysed the surgery reconstruction and the gastric stump, the duodenum and the jejunum mucosa aspects. The histopathological evaluation included looking for Helicobacter pylori by using two different methods: histology and urease test. CASUISTIC AND METHODS Fifty-nine patients, 44 (74.6%) male, median age 55.5 years old (range from 31 to 77 years old), who underwent a clinical interview and an upper digestive endoscopy. Paraffin blocks from the surgical specimen were reviewed in order to find out if the patients did have or did not have Helicobacter pylori before surgery. RESULTS The final results show that most of the patients had very good and good clinical evolution (Visick I e II) in 96%. The most common symptoms on late postoperative are mild dyspepsia with or without Helicobacter pylori, and diarrhea, anemia and dumping occurred in, respectively, 11 (18.6%), 2 (3.4%) and 2 (3.4%) cases. The Billroth I reconstruction had the best clinical results on statistical rate. The endoscopic finding showed normal results in the most number of cases, and reflux alkaline gastritis or erosive gastritis in a few cases. Ulcer recurrences were diagnosed in two patients (3.4%), and both had positive Helicobacter pylori. Most of the patients had Helicobacter pylori (86%) before surgery and also in the postoperative time (89.9%). CONCLUSIONS The patients had a very good clinical evolution after the gastrectomy. The Billroth I reconstruction had the best clinical results. The Helicobacter pylori is still present on gastric stump in late postoperative time, and we believe that it does not bring any negative influence to surgical results.

A new method for the experimental induction of secundary biliary cirrhosis in wistar rats

O objetivo desse experimento foi o desenvolvimento de um modelo de obstrucao do ducto biliar, atraves de procedimento cirurgico sem ligadura ou seccao do mesmo, que permitisse a evolucao para cirrose e mantivesse a via biliar extra-hepatica facilmente acessivel a eventuais manuseios. Foram utilizados 48 ratos Wistar, distribuidos em tres grupos: 32 animais foram submetidos a obstrucao do ducto hepatico comum (grupo OB), 9 foram submetidos a operacao simulada (grupo OS) e 7 foram adotados como controle para analise histologica (grupo OC). No desenvolvimento da tecnica, o ducto hepatico foi isolado logo apos sua emergencia justa-pancreatica, deixando-se 1 cm de ducto livre, reparado com fio de polipropileno. Em seguida procedeu-se a exposicao do apendice xifoide e, atraves de marcador de orelha de rato, foi feito um pequeno orificio circular. Passou-se, por este, o fio de polipropileno e tracionou-se ate o ducto biliar formar uma alca acima do orificio do apendice xifoide. Deste modo um cateter de silicone foi colocado sob esta alca. O ducto biliar permaneceu, portanto, tracionado e exposto entre a musculatura e a pele. O fechamento da parede muscular e da pele foi feito com sutura continua. A avaliacao histopatologica do figado destes animais e os efeitos bioquimicos sericos foram realizados apos 30 dias da obstrucao. Nos ratos do grupo OB ocorreu aumento significativo nas dosagens sericas da bilirrubina, das aminotransferases (ALT e AST), da fosfatase alcalina, da gamaglutamiltransferase e reducao significativa da albumina serica quando comparados aos valores das dosagens dos ratos do grupo OS. A analise histologica demonstrou a formacao de nodulos regenerativos em 68,7% dos casos do grupo OB, com presenca de fibrose portal (de grau leve e moderado) em 96,8% dos animais, acompanhada pela formacao de septos fibrosos (de grau moderado e intenso) em 87,4 %. Houve ainda intensa proliferacao de ductos biliares em 81,2%, e moderada em 18,7% dos casos. Conseguiu-se desta maneira, o desenvolvimento de um modelo experimental alternativo que provoca a interrupcao do fluxo bileo-duodenal, semelhante a oclusao das vias biliares, sem necessidade de ligadura, canulacao ou seccao do ducto biliar. A obstrucao biliar provocada pela tracao do ducto biliar oferece excelentes condicoes de pesquisa desde o momento da interrupcao do fluxo biliar ate o desenvolvimento de colestase, acompanhada pela distorcao da arquitetura hepatica, caracterizada por fibrose portal com formacao de septos e transformacao nodular multi-focal.

Prospective analysis between the therapy of immunosuppressive medication and allogeneic microchimerism after liver transplantation

After liver transplantation, migration of donor-derived hematopoietic cells to recipient can be detected in peripheral blood. This state is termed microchimerism. The aim of this study was to investigate prospectively the presence of allogeneic microchimerism, the occurrence of acute cellular rejection and the level of immunosuppression in transplanted patients. Microchimerism occurrence between 10 days and 12 months after liver transplantation was analyzed in 47 patients aged between 15 and 65 by a two-stage nested PCR/SSP technique to detect donor MHC HLA-DR gene specifically. A pre-transplant blood sample was collected from each patient to serve as individual negative control. Microchimerism was demonstrated in 32 (68%) of the 47 patients; of these, only 10 patients (31.2%) presented rejection. Early microchimerism was observed in 25 patients (78.12%) and late microchimerism in 7 patients (21.8%). Among the patients with microchimerism, 14 were given CyA and 18 were given FK506. In the group without microchimerism, 12 patients were given CyA and 03 were given FK506. There was a significant association between the presence of microchimerism and the absence of rejection (p=0.02) and also between microchimerism and the type of immunosuppression used. Our data indicate that microchimerism and probably differentiation of donor-derived leukocytes can have relevant immunologic effects both in terms of sensitization of recipient and in terms of immunomodulation toward tolerance induction.

Expanded Milan Criteria on Pathological Examination After Liver Transplantation: Analysis of Preoperative Data

BACKGROUND We sought to evaluate the accuracy of imaging techniques related to the Milan criteria (MC) compared with the explant histology and the survival of these patients. METHODS Between 1997 and 2006, we selected 45 cirrhotic patients with hepatocellular carcinoma distributed into two groups according to explant histology: MC and Expanded Milan Criteria (EMC). Age, gender, preoperative imaging (ultrasound [US] and/or computed tomography [CT]), maximal tumor dimension, number of tumors, explanted histology, histology degree, alpha-fetoprotein (AFP) level and vascular invasion were compared among the patients to evaluate the value of these prognostic factors for survival after liver transplantation. RESULTS By histology 42.2% explants were identified as EMC. The mean AFP level was 204.5 ng/mL. Vascular invasion was detected in 31.5% of explants and 68.4% showed incidental tumors. The survival rates after 10 years were 47.4% whereas MC patients showed 57.77%. The mean AFP level among MC patients was 150.2 ng/mL with vascular invasion detected in 7.7% of explants, and 47.4% with incidental tumors. The overall sensitivity of the imaging techniques was 83.3% for CT and 75% for US. The specificity was 96% for CT and 80.1% for US. CONCLUSION Scan examinations in the preoperative evaluation underestimated about 42.2% of tumors. Those patients had vascular invasion but the survival after 10 years was similar between the ECM and MC groups.

A laparoscopia no diagnóstico das doenças intra-abdominais. Análise de 168 casos

UNLABELLED The laparoscopy has been more and more frequently indicated in the last years, for the complementary diagnosis of intraabdominal diseases and abdominal repercussion of systemic diseases. Modern equipaments including videolaparoscopy and the use of either forceps or biopsy needle permit higher safety and significant diagnostic capacity. PURPOSE To perform laparoscopy for the diagnosis of intraabdominal and sistemic diseases. METHODS During the last 9 years 168 patients were submitted to laparoscopy and the main indications were: ascites--43 cases (25.5%); liver diseases--42 cases (25%); gastric cancer--37 cases (22%); lymphoma--17 cases (10.1%); abdominal tumour--9 cases (5.4%); peritoneal tuberculosis--8 cases (4.8%); liver tumour--6 cases (3.6%); mesenteric cyst--1 case (0.6%) and other diseases--5 cases (3.0%). Ninety nine patients were male (58.9%) aging from 9 to 78 years old (median 47.6 years). Liver biopsies were performed in 92 cases (54.7%) and other tumour biopsies in 26 cases (15.4%). RESULTS The diagnosis of the diseases were established or confirmed by laparoscopy in 145 patients (86.3%). In 25 cases of gastric cancer (67.5%) laparoscopy contraindicated the laparotomy, owing to advanced disease. Two patients presented bleeding (1.2%) after liver biopsies and laparotomy was immediately indicated. One of them, whose diagnosis was systemic lupus, presented abdominal abscess, bronchopneumony and died (0.6%). CONCLUSION Laparoscopy has small number of complications, and when employed as a diagnostic complementary method therapeutic procedures, avoids laparotomies and accelerate therapeutic procedures.The laparoscopy has been more and more frequently indicated in the last years, for the complementary diagnosis of intraabdominal diseases and abdominal repercussion of systemic diseases. Modern equipaments including videolaparoscopy and the use of either forceps or biopsy needle permit higher safety and significant diagnostic capacity. PURPOSE: To perform laparoscopy for the diagnosis of intraabdominal and sistemic diseases. METHODS: During the last 9 years 168 patients were submitted to laparoscopy and the main indications were: ascites - 43 cases (25,5%); liver diseases - 42 cases (25%); gastric cancer - 37 cases (22%); lymphoma - 17 cases (10,1%); abdominal tumour - 9 cases (5,4%); peritoneal tuberculosis - 8 cases (4,8%); liver tumour - 6 cases (3,6%); mesenteric cyst - 1 case (0,6%) and other diseases - 5 cases (3,0%). Ninety nine patients were male (58,9%) aging from 9 to 78 years old (median 47,6 years). Liver biopsies were performed in 92 cases (54,7%) and other tumour biopsies in 26 cases (15,4%). RESULTS: The diagnosis of the diseases were established or confirmed by laparoscopy in 145 patients (86,3%). In 25 cases of gastric cancer (67,5%) laparoscopy contraindicated the laparotomy, owing to advanced disease. Two patients presented bleeding (1,2%) after liver biopsies and laparotomy was immediately indicated. One of them, whose diagnosis was systemic lupus, presented abdominal abscess, bronchopneumony and died (0,6%). CONCLUSION: Laparoscopy has small number of complications, and when employed as a diagnostic complementary method therapeutic procedures, avoids laparotomies and accelerate therapeutic procedures.