Mauro Nectoux

Colangiografia transoperatória em colecistectomia laparoscópica

With laparoscopic cholecystectomy, the intraoperative cholangiography has been motive of intense controversy. Some authors perform it routinely. They consider laparoscopic cholecystectomy only an alternative to open access and, in that case, must be the same as conventional procedure. On the other hand, many authors believe that few patients have a true indication to evaluate the biliary tree. These authors do selectively intraoperative cholangiography. We performed 309 laparoscopic cholecystectomies between may 1993 and june 1997. The records of these patients were reviewed. Our results and experience with intraoperative cholangiography are evaluated. We usually perform intraoperative cholangiography by cystic duct catheterization, whenever feasible and without risk of injury to the biliary tree. It was possible in 244 (78.9%) cases. The main cause of unsuccessful was the presence of narrow cystic duct and occurred in 21 (6.8%) patients. The exam was normal in 229 (93.8%). Unsuspected choledocholithiasis was detected in six (2.4%), cystic duct draining into right hepatic duct was present in three (J.2%)and one (0.4%) had a choledocal cyst. The intraoperative cholangiography was a safe procedure in our patients who underwent laparoscopic cholecystectomy and, with our results, we recommend your routinely employment.

É possível diminuir o sangramento em hepatectomias sem a realização de exclusão vascular total ou parcial?: Resultados do uso de radiofrequência bipolar com agulhas resfriadas

BACKGROUND: Although the resection is the chosen procedure in the therapeutic treatment of liver malign lesions, the bleeding represents a factor of morbidity with a great impact in the hepatic surgery. With the means of minimizing this complication, several technological options have been utilized, being radiofrequency more recently among them, allowing the procedure to be realized with smaller incisions, without the need of vascular clamping, with minimum hepatic dissection, or bleeding. AIM: To present the results of the use of a new technique of hepatic parenchyma resection through parallel needles of bipolar radiofrequency developed by the authors themselves, verifying the impact in the trans-operation bleeding of patients subjected to hepatectomies. METHODS: Sixty patients were submitted to hepatic resection through the use of bipolar radiofrequency. The pre-operation bleeding was evaluated through the medication of the collected volume in the vacuum and by the weight difference in the compresses utilized during the procedure. All cases were monitored in their hepatocitary function through laboratory tests during the first week of the post-operation. RESULTS: The hepatic resections were realized with the mean of 87 minutes, mean incision size of 14 cm and mean bleeding of 58 ml. None of the patients received blood transfusion or derivatives. Central venous catheters were not utilized. All patients obtained fast anesthetic recuperation, leaving the recuperation room to the ward in less than 12 hours. The post-operation drainage was noted down until the drain removal occurring in all patients. The mean hospitalization time was of 3,2 days. After the elevation peak of the hepatic function tests in the first three days, all patients presented regression of them in a one month. CONCLUSION: It is possible, feasible and valid to use radiofrequency needle to perform hepatectomy, even larger ones, reducing bleeding.

Estenoses biliares benignas: reparação e resultados com o uso de silastic transhepático transanastomótico

BACKGROUND: The medical advances is not always related to homogeneous good results for all the patients. This is the case of laparoscopic cholecystectomy, whose advantages are largely recognized in the medical literature. However, this operation most dreaded complication, iatrogenic major bile duct injury, is rising in the last years, despite the learning curve, and stabilized in a level higher than that experienced in open cholecystectomy. Among the features which can bring to this event a good outcome is the use of transhepatic transanastomotic tubes in association with the corrective hepaticojejunostomy. AIM: To report a 20 years experience on biliary reconstruction of bile duct injuries with the use of transhepatic transanastomotic tubes. METHODS: Data were analysed from 338 patients who underwent operation for major bile duct injuries between January 1988 and December 2009. RESULTS: All the 338 patients were submitted to Roux-en-Y hepaticojejunostomy (Hepp-Couinaud approach) or distinct cholangiojejunostomies, all with the use of transhepatic transanastomotic silastic tubes. A successful long-term result was achieved in 240 (92,9%) of 338 patients, including those who required subsequent procedures. CONCLUSION: Benign bile duct strictures near the hepatic duct confluence remains a surgical challenge. The use of silastic transhepatic transanastomotic tubes in high biliary tract reconstruction is an option which can provides a successful repair of bile duct injuries with low complication rates.

Características construtivas e funcionais das agulhas de radiofrequência bipolares resfriadas para reduzir o sangramento nas ressecções hepáticas

Background - To reduce bleeding in liver resection various technological options have been disclosed, among them the radiofrequency. The intent of the various methods is to avoid vascular clamping, less liver dissection and minimize bleeding. Aim - To present a new technique of parallel bipolar radiofrequency needles developed by the authors and the technical details. Methods - The needle system has two parallel electrodes (18 gauge each) of 25 cm in length, separated by a distance of 1.5 cm, and only distal 4 cm dissipate energy generated by a bipolar electrocautery. These needles are cooled by an internal cooling system for continuous flow of cold sterile distilled water at 0oC, whose temperature is maintained through the presence of sterile distilled water ice. The operation is performed under general anesthesia and is not used central venous catheters during or after the procedure. The incisions may be right subcostal and median supra-umbilical. Results - The inical use in liver resection showed an average 87 minutes operation time, average size of abdominal incision of 14 cm and 58 ml of blood loss during surgery. No patient in the inical group received transfusion of blood or blood products. Conclusion - The bipolar radiofrequency cooled needles are viable and reduce bleeding in liver resection. ABCDDV/785

Fístula cervical pós-anastomose esofagogástrica: é possível diminuir a ocorrência?

INTRODUCAOA esofagectomia e procedimento cirurgico complexo e tradicionalmente associado a morbidade significativa, tendo como principal indicacao o tratamento da doenca maligna. Neste caso, apesar dos progressos em outras modalidades terapeuticas, a esofagectomia persiste como tratamento de escolha em pacientes com tumores poten-cialmente ressecaveis, tanto com intento curativo quanto paliativo. Entretanto, na afeccao maligna, cerca de 75% dos pacientes ja apresentam doenca avancada no momento do diagnostico

Colelitíase e cirrose hepática

Considerando que sao duas doencas frequentes na populacao, a associacao entre cirrose hepatica e colelitiase tambem e um achado comum. E importante o conhecimento desta situacao porque a evolucao clinica da cirrose pode ser complicada pela presenca de colelitiase e, ao contrario, uma colelitiase sintomatica pode ser de dificil tratamento nos pacientes cirroticos. Os autores fazem uma revisao da literatura enfocando os aspectos clinicos e terapeuticos desta associacao.