Marcelo Moura Linhares

Ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS): experiência brasileira

RACIONAL: Insuficiencia hepatica pos-operatoria devido a remanescente hepatico pequeno tem sido complicacao temida em pacientes que sao submetidos a resseccao hepatica extensa. A ligadura da veia porta associada a biparticao do figado para hepatectomia em dois estagios (ALPPS) foi desenvolvida recentemente com a finalidade de induzir rapida e significante regeneracao do figado para pacientes em que o tumor e previamente considerado irressecavel. OBJETIVO: Apresentar a experiencia brasileira com o ALPPS. METODO: Foram analisados 39 pacientes submetidos ao procedimento ALPPS em nove hospitais. Ele foi realizado em duas etapas. A primeira operacao consistiu em ligadura do ramo direito da veia porta e biparticao hepatica. Na segunda, os ramos direito da arteria hepatica, via biliar e veia hepatica foram ligados e o lobo hepatico direito estendido foi removido. Foram 22 pacientes do sexo masculino (56,4%) e 17 do feminino (43,6%). A media de idade foi 57,3 anos (variando de 20 a 83 anos). RESULTADOS: A indicacao mais comum foi metastase hepatica em 32 pacientes (82,0%), seguida por colangiocarcinoma em tres pacientes (7,7%). Dois morreram neste intervalo e nao foram submetidos a segunda operacao. O intervalo medio da primeira para a segunda operacao foi de 14,1 dias (variando de 5-30 dias). O volume do segmento lateral esquerdo apresentou aumento de 83% (variando de 47-211,9%). Morbidade significante foi observada em 23 pacientes (59,0%). A mortalidade foi de 12,8% (cinco pacientes). CONCLUSAO: O procedimento ALPPS permite resseccao hepatica em pacientes com lesoes consideradas previamente irressecaveis por induzir rapida hipertrofia do figado evitando a insuficiencia hepatica na maioria dos pacientes. Porem ainda apresenta elevada morbidade e mortalidade.

Liver retransplantation : A model for determining long-term survival

Background. Because of the worse results from retransplantation in relation to the initial liver transplantation, there is a need to refine the indication for retransplantation, such that fair distribution of this benefit is obtained. Methods. This was a study of 139 patients who underwent liver retransplantation. Thirty variables were studied: 18 relating to the recipient and 12 to the donor. All the independent variables were initially compared with the length of survival using univariate analyses. Variables presenting significance were compared with the dependent variable of length of survival, to determine which factors were related to longer survival among patients, when evaluated together. Results. A multivariate model for determining long-term survival among patients with retransplants was built up using the following variables: recipients age, creatinine, urgency of retransplantation and early failure of the first graft. Through this multivariate model it was possible to determine a score that was categorized according to tertile distributions (below the 33rd percentile, score <24; 33rd to 66th percentile, 24 ≤ score ≤ 32; above the 66th percentile, score > 32). One-year, 3-year, and 5-year patient survival rates following retransplantation were respectively 85%, 82%, and 77% for scores <24; 69%, 66%, and 61% for scores between 24 and 32; and 21%, 19%, and 16% for scores >32 (P<0.0001). Conclusion. The variables of recipients age, creatinine, urgency of retransplantation, and early failure of the initial transplantation were factors that were independently related to the long-term survival of patients with liver retransplants.

New Trends in Diffusion-Weighted Magnetic Resonance Imaging as a Tool in Differentiation of Serous Cystadenoma and Mucinous Cystic Tumor: A Prospective Study

Background/Aims: Pancreatic cystic lesions are increasingly being recognized. Magnetic resonance imaging (MRI) is the method that brings the greatest amount of information about the morphologic features of pancreatic cystic lesions. To establish if diffusion-weighted MRI (DW-MRI) can be used as a tool to differentiate mucinous from nonmucinous lesions. Methods: Fifty-six patients with pancreatic cystic lesions (benign, n = 46; malignant, n = 10) were prospectively evaluated with DW-MRI in order to differentiate mucinous from nonmucinous lesions. Final diagnosis was obtained by follow-up (n = 31), surgery (n = 16) or endoscopic ultrasound-guided fine needle aspiration (n = 9). Serous cystadenoma was identified in 32 (57%) patients. Results: The threshold value established for the differentiation of mucinous from nonmucinous lesions was 2,230.06 s/mm2 for ADC of 700. DWI-MRI behavior between mucinous and nonmucinous groups revealed sensitivity, specificity, positive predictive value, negative predictive value and accuracy to be 80, 98, 92, 93 and 93%, respectively (p < 0.01, power of sample = 1.0). In the comparison of the diffusion behavior between mucinous (n = 13) and serous (n = 32) lesions, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 100, 97, 92, 100 and 98%, respectively (p < 0.01, power of sample = 1.0). The results of endoscopic ultrasound-guided fine needle aspiration were similar to those of DW-MRI. Conclusions: DW-MRI can be included as part of the array of tools to differentiate mucinous from nonmucinous lesions and can help in the management of pancreatic cystic lesions.

SOLID PSEUDOPAPILLARY NEOPLASM OF THE PANCREAS

ABSTRACT Background: The solid pseudopapillary neoplasm is a rare tumor of the pancreas. However, it´s etiology still maintain discussions. Aim: To analyze it´s clinical data, diagnosis and treatment. Methods: A retrospective study of medical records of all patients treated from January 1997 until July 2015. Results: Were identified 17 cases. Most patients were women (94.11%) and the average age was 32.88 years. The main complaint was abdominal mass (47.05%). The most frequent location was in the body/tail of the pancreas (72.22%) and the most frequently performed surgery was distal pancreatectomy with splenectomy (64.70%). No patient had metastases at diagnosis. Conservative surgery for pancreatic parenchyma was performed in only three cases. The rate of complications in the postoperative period was 35.29% and the main complication was pancreatic fistula (29.41%). No patient underwent adjuvant treatment. Conclusions: The treatment is surgical and the most common clinical presentation is abdominal mass. Distal pancreatectomy with splenectomy was the most frequently performed surgery for its treatment.

Transplante de pâncreas e ilhotas em portadores de diabetes melito

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

Charcot neuroarthropathy after simultaneous pancreas-kidney transplant.

Background Immunosuppressive regimen is associated with several metabolic adverse effects. Bone loss and fractures are frequent after transplantation and involve multifactorial mechanisms. Methods A retrospective analysis of 130 patients submitted to simultaneous pancreas-kidney transplantation (SPKT) and an identification of risk factors involved in de novo Charcot neuroarthropathy by multivariate analysis were used; P<0.05 was considered significant. Results Charcot neuroarthropathy was diagnosed in 4.6% of SPKT recipients during the first year. Cumulative glucocorticoid doses (daily dose plus methylprednisolone pulse) during the first 6 months both adjusted to body weight (>78 mg/kg) and not adjusted to body weight were associated with Charcot neuroarthropathy (P=0.001 and P<0.0001, respectively). Age, gender, race, time on dialysis, time of diabetes history, and posttransplantation hyperparathyroidism were not related to Charcot neuroarthropathy after SPKT. Conclusions Glucocorticoids are the main risk factors for de novo Charcot neuroarthropathy after SPKT. Protocols including glucocorticoid avoidance or minimization should be considered.

Laparoscopic Management of Hepatic Cysts

The present study describes the technique and evaluation of postsurgical results, hospital stay, and follow-up of patients who underwent hepatic cyst surgical treatment by laparoscopic access. Twelve patients presenting liver cystic disease were included in this research. Clinical conditions, laboratorial and radiologic examinations, surgical technique, complications, and postoperative follow-up were discussed. In our series, the morbidity rate was 25%. No mortality was observed in the postoperative period. Conversion to open surgery was necessary in 1 case, owing to hemorrhage. No recurrence was found and patients remain asymptomatic in their current follow-up. Laparoscopic resection of hepatic cyst proved to be efficient in the regression of the cysts and resulted in disappearance of symptoms.

Genetic and Immunohistochemical Expression of Integrins ITGAV, ITGA6, and ITGA3 As Prognostic Factor for Colorectal Cancer: Models for Global and Disease-Free Survival.

Objective To evaluate the relationship between the expression profiles of 84 extracellular matrix (ECM) genes and the prognosis of patients with colorectal cancer (CRC). Methods This retrospective study included 114 patients with stage I–IV CRC who underwent primary tumour resection. Quantitative real-time PCR and immunohistochemistry assays were conducted using primary tumour samples. Kaplan-Meier survival curves were also generated to identify differences in global survival (GS) and disease-free survival (DFS) for the hypo- or hyperexpression status of each marker. The log-rank test was used to verify whether the differences were significant. Stepwise Cox regression models were also used to identify the risk factors associated with GS and DFS in a multivariate mode, and then were used to score the risk of death associated with each marker, either independently or in association. Results In the univariate analyses, significant differences in GS in relation to the expression profiles of ITGAV (p = 0.001), ITGA3 (p = 0.002), ITGA6 (p = 0.001), SPARC (p = 0.036), MMP9 (p = 0.034), and MMP16 (p = 0.038) were observed. For DFS, significant differences were observed in associated with ITGAV (p = 0.004) and ITGA3 (p = 0.001). However, only the ITGAV and ITGA6 gene markers for GS (hazard ratio (HR) = 3.209, 95% confidence interval (CI) = 1.412–7.293, p = 0.005 and HR = 3.105, 95% CI = 1.367–7.055, p = 0.007, respectively), and ITGA3 for DFS (HR = 3.806, 95% CI = 1.573–9.209, p = 0.003), remained in the final Cox regression models. A scoring system was developed to evaluate the risk of patient death based on the number of markers for the components of the final GS model. Scores of 0, 1, or 2 were associated with the following mean survival rates [CI]: 47.162 [44.613–49.711], 39.717 [35.471–43.964], 30.197 [24.030–36.327], respectively. Conclusions Multivariate mathematical models demonstrated an association between hyperexpression of the ITGAV and ITGA6 integrins and GS, and also between the ITGA3 integrin and DFS, in patients with colorectal tumours. A risk scoring system based on detected hyperexpression of 0, 1, or 2 markers (e.g., ITGAV and/or ITGA6) was also found to accurately correlate with the GS curves generated for the present cohort.

Variation of the Rex shunt for treating concurrent obstruction of the portal and superior mesenteric veins

Children with extrahepatic portal vein obstruction can be managed successfully by surgical intervention and should be evaluated for potential meso-Rex bypass. A Rex shunt variation is described to treat portal and superior mesenteric vein thrombosis. This technique uses the internal jugular vein as a conduit between the splenic vein and the left portal vein with splenic preservation.

Parenteral nutrition versus enteral nutrition in severe acute pancreatitis

PURPOSE To compare the effect of parenteral versus enteral nutritional support in severe acute pancreatitis, with respect to efficacy, safety, morbidity, mortality and length of hospitalization. METHODS The study was comprised of 31 patients, divided into a parenteral group (n=16) and an enteral group (n=15), who met severity criteria for abdominal tomography (Balthazar classes C, D, and E). The patients were compared by demographics, disease etiology, antibiotic prophylaxis, use or not of somatostatin, nutritional support, complications and disease progression. RESULTS There was no statistical difference in the average duration of nutritional support, somatostatin, or antibiotics in the two groups. Imipenem was the drug of choice for prophylaxis of pancreatic infections in both groups. More complications occurred in the parenteral group, although the difference was not statistically significant (p=0.10). Infectious complications, such as catheter sepsis and infections of the pancreatic tissue, were significantly more frequent in the parenteral group (p=0.006). There was no difference in average length of hospitalization in the two groups. There were three deaths in the parenteral group and none in the enteral group. CONCLUSION Enteral nutritional support is associated with fewer septic complications compared to parenteral nutritional support.