Marcelo Garcia Toneto

The Role of Ultrasound in the Diagnosis of Hepatic Steatosis in Morbidly Obese Patients

Background: Hepatic steatosis is prevalent in obese patients. Although it requires histology for diagnosis, ultrasound may indicate its presence. We evaluated the importance of ultrasound in the diagnosis of steatosis in morbidly obese patients, and considered its clinical relevance for patients with BMI of 35-40 kg/m2 without co-morbidities. Methods: 187 morbidly obese patients submitted to bariatric surgery were prospectively studied. All patients had ultrasound before the operation, and hepatic biopsies during the operation, which were compared. Results: The prevalence of steatosis histologically was 91.4%. The sensitivity and specificity of ultrasound in diagnosing steatosis was 49.1% and 75%, respectively,with a positive predictive value of 95.4%. Conclusion: The biopsies found a very high prevalence of steatosis in the studied population. The ultrasound results yielded a high positive predictive value (95.4%), suggesting its use as a diagnostic tool for this co-morbidity in morbidly obese patients.The low sensitivity of the method could be related to the lack of objective criteria for the ultrasound diagnosis of steatosis, and probably, technical problems in performing ultrasound in such patients. We believe that in patients with a BMI of 35-40 kg/m2 without other comorbidities, the ultrasound finding of steatosis could be of value as an indication for bariatric surgery.

Hepatic Steatosis In Patients Undergoing Bariatric Surgery and its Relationship to Body Mass Index and Co-Morbidities

Background: Although non-alcoholic hepatitis usually is asymptomatic and benign, this condition may progress to cirrhosis and hepatic failure. Some findings are similar to alcoholic hepatitis, but there is no history of excessive alcohol consumption. Among the factors associated with non-alcoholic hepatitis, obesity, diabetes and dyslipidemia are the most important. Methods: 77 consecutive patients undergoing bariatric surgery had their liver biopsy compared to the presence of co-morbidities and BMI. Results: 67 patients (87.1%) had an abnormal liver biopsy, mostly due to steatosis (83.1%), but also steatohepatitis (2.6%) and cirrhosis (1.3%). The degree of liver damage was related to higher BMI scores. Co-morbidities were present in 46.9% of the patients with hepatic steatosis. Conclusions: The authors suggest that a liver biopsy should be performed in all patients at bariatric surgery, in order to evaluate possible liver damage and to assist postoperative care.

Synchronous gastrointestinal stromal tumors (GIST) and other primary cancers: Case series of a single institution experience

BACKGROUND Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasm affecting the gastrointestinal tract. The incidental occurrence of mesenchymal tumors and other primary tumors has not been well described in literature. OBJECTIVE The aim of this study was to evaluate the clinical and pathologic features of GIST occurring synchronously with other primary tumors. METHODS Forty-three patients with diagnosis of GIST treated surgically with curative intent at our institution from 1998 to 2006 were included. The patient clinical data and pathological reports were reviewed. RESULTS Of the 43 patients, there were 6 (14%) cases of synchronous GIST and other primary tumors discovered as coincidental findings. The synchronous GISTs analyzed were located in the stomach (50%) and small intestine (50%), size ranging from 0.7 to 7.6 cm (median 3.35 cm). Five (83%) of the concurrent primary tumors were from gastrointestinal origin and only one (17%) patient presented with concurrent breast cancer and GIST. The synchronous GISTs immunofenotype shows positivity for CD117 and CD34 (100%), smooth-muscle actin (SMA) (67%), S100 (50%) and desmin (33%). Whereas staining for cytokeratin AE1/AE3 and PDGF were all negative. According to GIST risk category for aggressive behavior three were classified as very low, one intermediate and two high. CONCLUSIONS The synchronous occurrence of GISTs and other primary neoplasm is not an uncommon entity and usually they are discovery incidentally. Epithelial tumors of the gastrointestinal tract are the most associated with concomitant GISTs. Further studies are required to clarify the molecular and genetic mechanisms of carcinogenesis and progression associating GIST and synchronous tumors.

Gastrectomia em pacientes idosos: análise dos fatores relacionados a complicações e mortalidade

OBJETIVO: Verificar as variaveis que influenciam os resultados pos-operatorios no tratamento do adenocarcinoma gastrico em pacientes idosos. METODO: Foi realizada uma coorte historica onde as principais variaveis em estudo foram: idade, localizacao do tumor, estadiamento, doencas associadas, complicacoes do procedimento cirurgico e mortalidade operatoria. Os pacientes foram separados em dois grupos em relacao a idade [Grupo I (< 65 anos) e Grupo II ( 65 anos)], de maneira que os fatores associados com maior mortalidade fossem analisados de forma independente. RESULTADOS: Foram avaliados 160 pacientes submetidos a resseccao gastrica. A media de idade foi 60,7 anos. Presenca de doencas associadas, classificacao ASA III ou IV e mortalidade operatoria foram associados com individuos mais velhos. Nao houve diferenca entre os grupos em relacao a localizacao do tumor no estomago, resseccao empregada, estagio dos tumores e complicacoes pos-operatorias. A mortalidade operatoria foi 6,1% no Grupo I e 12,9% no Grupo II. O principal fator de risco para o obito na analise univariada foi a presenca de doencas associadas (p<0,03). Na analise multivariada, o unico fator de risco significativo para maior mortalidade foi classificacao ASA mais avancada. CONCLUSAO: Os idosos operados por adenocarcinoma gastrico apresentam fator de risco mais acentuado de morte pos-operatoria. Contudo, a idade cronologica nao pode ser definida como um fator determinante, e sim circunstâncias de doencas associadas e condicoes fisiologicas que os acompanham nessa faixa etaria.

Linfadenectomia ampliada (D2) no tratamento do carcinoma gástrico: análise das complicações pós-operatórias

BACKGROUND: The aim of this study was to describe and analyze the postoperative complications and the survival of patients submitted to gastric resection with extended lymphadenectomy. METHODS: In a historical cohort, data of patients with gastric carcinoma submitted to D2 lymphadenectomy were studied. The main variables analyzed were: age, tumor location, stage, surgical procedure complications, pattern of tumor recurrence and overall survival. RESULTS: Thirty-five patients were studied during the period between January 2000 and December 2004. Mean age of the patients was 57 years. Only one (2.9%) patient had early gastric cancer. The most common site was in the middle-third of the stomach. The number of resected nodes per patient ranged from 15 to 80 (mean of 28.8). Twenty-six (74.3%) patients had metastatic lymph nodes, with mean of 13.4 (±11.8) positive nodes per patient. Six (17.1%) patients had complications in the postoperative period, including two pneumonias, one pancreatic fistula, one duodenal stump fistula, and two esophagojejunal leakage. Only one (2.86%) patient died of operative complications. The meantime of follow-up was 26 months. Twenty-two patients were alive at the conclusion of the study, with a current actuarial survival of 62.9%. CONCLUSION: The results of this study suggest that, in specialized centers, gastrectomy with D2 lymphadenectomy is a procedure with acceptable levels of complications, and can be performed without increasing the postoperative mortality.

CURRENT STATUS OF THE MULTIDISCIPLINARY TREATMENT OF GASTRIC ADENOCARCINOMA

ABSTRACT Background: The complexity of the management of gastric cancer requires a multidisciplinary evaluation of patients with this tumor. Several treatments have been employed, associated to the surgical resection. Objective: To review the available therapeutic alternatives for the treatment of gastric adenocarcinoma. Methods : A review of selected articles on multidisciplinary treatment of gastric adenocarcinoma in the Pubmed and Medline databases between 2000 and 2017 was carried out. The following headings were related: stomach cancer, treatment, chemotherapy and radiotherapy. Results : There are several valid alternatives, with good results for the treatment of gastric cancer: chemoradiotherapy or chemotherapy in the adjuvant scenario; perioperative chemotherapy; and chemoradiotherapy after neoadjuvance with isolated chemotherapy. Conclusion : Current evidences suggest that combined multidisciplinary treatment is superior to surgery alone. However, the optimal treatment regimen is not yet established, and depends on a number of factors, especially the type of surgical resection employed. Therefore, the therapeutic decision should be made by a multidisciplinary team, assessing patient’s personal characteristics, biology of the tumor, residual disease, risks and side effects.

The history of the parathyroid surgery

The authors conducted a review of the major aspects of progression of knowledge about the surgical treatment of hyperparathyroidism. Through literature review, we analyzed articles on the history of the evolution of anatomical, physiological, pathological and surgical knowledge of the parathyroid glands. Because of their unique anatomical features, the parathyroid glands were the last of the endocrine glands to be discovered, which greatly hindered proper treatment until the first decades of the twentieth century. Technological developments in the last 30 years greatly facilitated the location of the glands and hyperparathyroidism surgery. However, an experienced and dedicated surgeon is still essential to the excellence of treatment. RESUMO Os autores fizeram uma revisão dos principais aspectos históricos da progressão do conhecimento sobre o tratamento cirúrgico do hiperparatireoidismo. Por meio de revisão bibliográfica, foram analisados artigos selecionados sobre a história da evolução do conhecimento anatômico, fisiológico, patológico e cirúrgico das glândulas paratireoides. Devido às suas características anatômicas peculiares, as paratireoides foram as últimas das glândulas endócrinas a serem descobertas, o que dificultou sobremaneira seu tratamento adequado até as primeiras décadas do Século XX. A evolução tecnológica ocorrida nos últimos 30 anos facilitou sobremaneira a localização das glândulas e a cirurgia do hiperparatireoidismo. Contudo, um cirurgião experiente e dedicado ao tratamento dessa enfermidade ainda é fundamental para a excelência do tratamento.

DO PROXIMAL AND DISTAL GASTRIC TUMOURS BEHAVE DIFFERENTLY

ABSTRACT Background: Although the incidence of gastric (adenocarcinoma) cancer has been decreasing over time, it is still one of the most common malignancies worldwide, and proximal tumours tend to have a worse prognosis. Aim: To compare surgical outcomes and prognosis between proximal - excluding tumours of the cardia - and distal gastric cancer. Methods: Out of 293 cases reviewed - 209 with distal and 69 with proximal gastric cancer - were compared for clinical and pathological features, stage, surgical outcome, mortality and survival. Results: Statistically, there was no significant difference between patients in both groups regarding mortality (p=0.661), adjuvant chemotherapy (p 0.661), and radiation (p=1.000). However, there was significant difference in the degree of lymph node dissection employed (p=0.002) and the number of positive lymph nodes resected (p=0.038) between the two groups. The odds of death at five years for patients who had a D0 dissection was three times greater (odds ratio 2.78; (95%CI 1.33-5.82) than that for patients who had a D2 dissection, while for patients who had a D1 dissection the odds ratio was only 1.41 (95%CI 0.71-2.83) compared to D2-dissected patients. Conclusion: Although no significant differences were found between proximal and distal gastric cancer, the increased risk of death in D0- and D1-dissected patients clearly suggests an important role of radical D2 lymph node dissection in survival.

Unusual Cause of a Hepatic Mass.

A woman in her 40s was referred to our service owing to unusual findings detected on routine abdominal ultrasonography ordered by her gynecologist. The ultrasonographic scan showed a hepatic mass in the right lobe composing approximately 50% of the liver parenchyma. The patient was asymptomatic, and there were no significant findings on abdominal physical examination— the liver was not palpable. Results of whole blood analyses, including α-fetoprotein, were within the reference ranges. She had not received any medication, including contraceptive pills or hormones, for more than 10 years. Nine years before this examination, the patient underwent elective splenectomy and hepatic biopsy at another institution. However, she did not know the reason for removal of the spleen, and results of the histopathologic examination were not available. She had undergone a cesarean section at age 25 years. The patient had no history of trauma or other previous medical events. An abdominal computed tomographic scan revealed a welldefined, solid, heterogeneous mass, completely intrahepatic, with no enhancement and no liquid component, causing slight displacement of the right hepatic vein (Figure 1). L R

Historical evolution of the surgical treatment of pancreatic cancer

Objetivos: Revisar os principais aspectos historicos da evolucao do tratamento do câncer de pâncreas.Fonte de dados: Revisao bibliografica atraves do PubMed. Foram analisados artigos selecionados sobre a historia do tratamento do câncer de pâncreas.Sintese dos dados: Resseccao cirurgica completa e a unica alternativa terapeutica que pode possibilitar a cura dos pacientes com câncer de pâncreas. Entretanto, a duodenopancreatectomia e um dos procedimentos cirurgicos mais desafiadores, necessitando cirurgioes com alto nivel de treinamento para sua execucao com seguranca. Diversos personagens estiveram envolvidos na evolucao da tecnica operatoria na cirurgia pancreatica ate que o procedimento atingisse os niveis de seguranca atuais.Conclusoes: Apesar da seguranca com a qual a duodenopancreatectomia e realizada atualmente, a sobrevida pos-operatoria no câncer de pâncreas ainda e insuficiente, sugerindo que as questoes tecnicas operatorias representam apenas uma das etapas necessarias para progresso dos resultados. Melhora no sistema de rastreamento, diagnosticando tumores mais precoces, identificacao de pacientes de alto risco e aperfeicoamento no tratamento adjuvante sao necessarios para aumentar a taxa de cura dessa neoplasia. Aims: To review the main historical aspects of the evolution of the treatment of pancreatic cancer.Source of data: Literature review through PubMed. Selected articles on the history of the treatment of pancreatic cancer were analyzed.Summary of findings: Complete surgical resection is the only therapeutic alternative that may allow cure of patients with pancreatic cancer. However, pancreaticoduodenectomy is one of the most challenging surgical procedures, requiring surgeons with a high level of training for its secure implementation. Several protagonists were involved in the evolution of the surgical technique in pancreatic surgery until the procedure reached current levels of security.Conclusions: Despite the safety with which pancreaticoduodenectomy is currently performed, postoperative survival in pancreatic cancer is still insufficient, suggesting that technical issues are just one of the steps needed to improve outcome. Better screening methods to diagnose earlier tumors, identification of high risk patients and improvement in adjuvant treatment are needed to increase the cure rate of this neoplasm.Aims: To review the main historical aspects of the treatment evolution of pancreatic cancer. Data source: Literature review through PubMed. Selected articles on the history of pancreatic cancer treatment were included. Summary of findings: Complete surgical resection is the only therapeutic alternative that can offer a cure to patients with pancreatic cancer. However, pancreaticoduodenectomy is one of the most challenging surgical procedures, requiring surgeons with a high level of training for its safe implementation. Several researchers have been involved in the evolution of surgical techniques in pancreatic surgery to reach the levels of safety currently presented by the procedure. Conclusions: Despite the safety with which pancreaticoduodenectomy is currently performed, postoperative survival in pancreatic cancer is still insufficient, suggesting that operative technical issues are just one of the steps needed to improve the outcome. Better screening methods that enable earlier diagnosis of tumors, identification of high-risk patients and improvements in adjuvant treatment are required to increase the cure rate for this neoplasm.